2026 AHA科学声明：急性心脏病住院患者的营养不良和恶病质

DISTINCTIONS BETWEEN MALNUTRITION AND CACHEXIA, SARCOPENIA, AND FRAILTY

Malnutrition, cachexia, sarcopenia, and frailty are phenotypically distinct but interconnected conditions with interrelated pathophysiological processes that lead to different magnitudes of wasting and susceptibility to adverse outcomes.$^{81-83}$ Sarcopenia is defined as the age-related loss of muscle mass and function, which can be exacerbated by chronic conditions, including CVD and potentially malnutrition. Frailty is a state of increased vulnerability

that further complicates clinical conditions, leading to elevated risk of adverse outcomes. Cachexia defined as a chronic catabolic syndrome characterized by unintentional edema-free weight loss, associated with anorexia, inflammation, and abnormal biochemistry, in the setting of an underlying disease.$^{84,85}$ The unintentional weight loss of cachexia is predominantly loss of muscle mass with or without loss of fat; however, not all individuals with sarcopenia are cachectic.$^{86}$ In fact, sarcopenic obesity, when lean mass wasting and fat mass expansion occur concurrently, is increasingly recognized and may incur a distinct phenotype of low physical functioning and higher mortality rates, especially in older adults with HF.$^{87,88}$

CLIMUAL STATEMENTS AND EMBULINES

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||Malnutrition in the context of acute illness or injury|Malnutrition in the context of chronic illness|Malnutrition in context of social/environmental circumstances (starvation)|||| |---|---|---|---|---|---|---| ||Moderate: protein-calorie malnutrition (E44.0)|Severe protein-calorie malnutrition (E43)|Moderate protein-calorie malnutrition (E44.0)|Severe protein-calorie malnutrition (E43)|Moderate protein-calorie malnutrition (E43)|Moderate protein-calorie malnutrition (E44.0)| |Protein-calorie malnutrition can occur at any BMI||||||| |Clinical characteristics: include all that apply||||||| |Energy intake: The clinician may obtain or review the food and nutrition history, estimate optimum energy needs, compare them with estimates of energy consumed, and report inadequate intake as a percentage of estimated energy requirements over time|<75% of estimated energy requirement for >7 d|≤50% of estimated energy requirement for ≥5 d|<75% of estimated energy requirement for ≥1 mo|<75% of estimated energy requirement for ≥1 mo|<75% of estimated energy requirement for ≥3 mo|<50% of estimated energy requirement for ≥1 mo| |Weight loss:|% Time|% Time|% Time|% Time|% Time|%| |Evaluate weight loss in light of other clinical findings, including hydration status. Weight change over time is reported as a percentage of weight lost (or weight change) from baseline. Equation: original weight-current weight/original weight $100=%$ weight change|1-2 1 wk|>2 1 wk|5 1 mo|>5 1 mo|>5 1 mo|>5 1 mo| |Evaluate weight loss in light of other clinical findings, including hydration status. Weight change over time is reported as a percentage of weight lost (or weight change) from baseline. Equation: original weight-current weight/original weight $100=%$ weight change|5 1 mo|>5 1 mo|7.5 3 mo|>7.5 3 mo|>7.5 3 mo|>7.5 3 mo| |Evaluate weight loss in light of other clinical findings, including hydration status. Weight change over time is reported as a percentage of weight lost (or weight change) from baseline. Equation: original weight-current weight/original weight $100=%$ weight change|7.5 3 mo|>7.5 3 mo|10 6 mo|>10 6 mo|>10 6 mo|>10 6 mo| |Muscle mass-physical assessment (all noted):|Mild depletion|Moderate depletion|Mild depletion|Severe depletion|Mild depletion|Severe depletion| |Muscle loss (eg, wasting of the temples (temporalis muscle), clavicles (pectoralis and deltoids), shoulders (deltoids), interosseous muscles, scapula (latissimus dorsi, trapezius, deltoids), thigh (quadriceps), and calf (gastrocnemius)|Mild depletion|Moderate depletion|Mild depletion|Severe depletion|Mild depletion|Severe depletion| |Body fat-physical assessment (all noted):|Mild depletion|Moderate depletion|Mild depletion|Severe depletion|Mild depletion|Severe depletion| |Loss of subcutaneous fat (eg, orbital, triceps, overlying ribs)||||||| |Fluid accumulation-physical assessment:|Mild|Moderate-severe|Mild|Severe|Mild|Severe| |Generalized or localized fluid accumulation evident on examination (extremities, vulvar/scotal, or ascites)||||||| |Functional assessment: Handgrip strength: Consult normative standards supplied by the manufacturer of the measurement device|NA|Measurably reduced|NA|Measurably reduced|NA|Measurably reduced|

A minimum of 2 of the 6 characteristics above is recommended for diagnosis of either severe or moderate protein-calorie malnutrition. Usual weight should be obtained to determine the percentage and to interpret the significance of weight loss. International Classification of Diseases, 10th Revision code displayed under diagnostic term. The National Center for Health Statistics defines chronic as a disease or condition lasting ≥3 months.

ASPEN indicates American Society for Parenteral and Enteral Nutrition; BMI, body mass index; and NA, not applicable.

Source: Academy of Nutrition and Dietetics and ASPEN consensus characteristics of adult malnutrition.$^{1}$

Criteria for cachexia have variously ranged from unintentional edema-free body weight loss ≥7.5% of previous normal weight over the prior 6 months$^{89}$ to ≥5% body weight loss over ≤12 months or absolute BMI <20 kg/m$^{2}$ accompanied by 3 of 5 criteria: decreased muscle strength, fatigue, anorexia, low fat-free mass index, or abnormal biochemistry.$^{84}$ A practical consensus definition of cardiac cachexia has been proposed as “a catabolic syndrome in patients with symptomatic HF characterized by muscle mass loss (by physical exam or imaging methods) and unintentional edema-free weight loss (≥5% pre-HF body weight), in which dietary macronutrient intake may be sufficient or insufficient.”$^{90}$ Aging and chronic diseases such as CVD are 2 principal risk factors for the wasting continuum, and these conditions adversely influence outcomes for older adults with CVD at greater risk of

disability and mortality.$^{91,92}$ Recognizing and differentiating between malnutrition, sarcopenia, and cachexia is clinically important because these conditions differ in their scope for reversibility and appropriate interventions. For example, malnutrition, especially when contributed to by inadequate intake due to dietary restrictions, frequent fasting for procedures, or food insecurity, may be addressed by initiatives that focus on food access and education, whereas the current pathophysiological paradigm supports underlying cardiac disease treatment as the only intervention that substantially reverses cardiac cachexia.$^{90}$ If weight loss or muscle wasting persists despite adequate protein calorie provision, cachexia is likely the more appropriate diagnosis. If the weight, fat, or muscle loss can be halted by improving nutrient intake and absorption, malnutrition is likely the dominant diagnosis.

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PATHOPHYSIOLOGY OF MALNUTRITION AND CACHEXIA IN INPATIENTS WITH CARDIAC CONDITIONS

Patients with malnutrition typically have inadequate intake of the macronutrients, including protein, carbohydrates, and fats, needed to support energy requirements, as well as the micronutrients, including vitamins and minerals, that are required for physiological processes, enzymatic functions, and immunity. Nutritional insufficiency refers to nutrient intake below the recommended or beneficial range; deficiency describes a more severe intake decrement that results in a disease state (eg, clinical syndromes from vitamin deficiency). In settings of insufficient protein intake, homeostatic mechanisms in skeletal muscle will diminish amino acid turnover such that the body limits nitrogen excretion in the urine. Thus, the body conserves all available protein substrate for essential functions. Chronic negative nitrogen balance leads to progressive erosion of lean body mass, impaired immune function, delayed wound healing, and overall deterioration in nutritional status.$^{93}$ Conversely, cardiac cachexia is characterized by a catabolic metabolism and accelerated turnover of protein stores, degrading fat-free mass and leading to elevated urine nitrogen excretion. The pathophysiological basis of this catabolic state is thought to stem from complex interplay between the neurohormonal dysregulation of the advanced HF (particularly HF with reduced ejection fraction) syndrome, chronic inflammation, myocardial substrate demands of the failing heart, abnormalities of mesenteric perfusion, and venous pressures and may be exacerbated by inadequate macronutrient intake in relation to the HF symptoms of anorexia and early satiety.$^{90}$

Risk factors for malnutrition in cardiac inpatients include advanced age, poor appetite, reduced dietary intake, and increased metabolic demands due to heart disease. These factors, along with comorbidities such as dental disease, chronic kidney disease (CKD), and dementia, significantly increase the risk of impaired dietary intake and nutrient absorption. Specifically in HF, a low-flow or congestive state impairs nutrient delivery and absorption, with associated decreased appetite, gastrointestinal dysfunction, and malnutrition.$^{94}$ In addition, cardiac medications such as digoxin, amiodarone, and mexiletine can lead to nausea and taste changes that exacerbate inadequate calorie intake. Furthermore, strict dietary counseling on sodium, saturated fat, and calories, as well as dietary patterns recommended for patients receiving warfarin anticoagulation or being managed for advanced kidney disease or diabetes, can lead to dietary confusion and inadequate protein-calorie intake. Repeated inpatient arrangements for nil per os (NPO) before procedures can further exacerbate poor dietary intake. Last, the limited meal options on hospital food menus are

frequently poor in taste and misaligned with cultural expectations of the patient population.

OPPORTUNITIES FOR NUTRITIONAL INTERVENTIONS IN THE INPATIENT AND POSTDISCHARGE SETTINGS

The Dietary Guidelines for Americans and American Heart Association Dietary Guidance provide a foundation for eating to promote cardiovascular health, emphasizing the consumption of nutrient-dense foods.$^{95}$ For patients with established cardiac conditions, the DASH (Dietary Approaches to Stop Hypertension), Mediterranean, and plant-based dietary patterns are broadly thought to be beneficial, although the evidence base in established disease is weaker than for primary CVD prevention. The DASH diet focuses on fruits, vegetables, whole grains, and lean proteins, promoting low sodium intake and rich potassium, magnesium, and calcium sources to manage blood pressure. The Mediterranean diet emphasizes healthy fats from olive oil, nuts, and fish, combined with a high intake of fruits, vegetables, and whole grains. Plant-based diets prioritize minimally processed plant foods, which are naturally low in unhealthy fats and high in fiber, vitamins, and minerals. It is also strongly recommended that patients avoid trans fats found in partially hydrogenated oils, and processed foods high in sodium, added sugars, and saturated fats, although limits on each of these components vary across conditions and guidelines.$^{95,96}$

SODIUM-HF (Study of Dietary Intervention Under 100 mmol in Heart Failure) provided new insights into sodium intake for patients with HF (any ejection fraction). This study demonstrated that a sodium-restricted diet (goal <1500 mg/d) did not significantly reduce the composite end point of cardiovascular-related admission to hospital, cardiovascular-related emergency department visit, or all-cause death compared with a usual-dodium diet (average intake, 2073 mg/d at 12 months).$^{97}$ Although HF guidance still favors avoidance of excessive sodium in those with congestive symptoms, the most stringent American Heart Association sodium guidance is for individuals with hypertension.$^{95}$ However, the focus on restrictive dietary counseling across the cardiometabolic conditions, whether for sodium in populations with HF, sugars for those with diabetes, saturated fats for those with coronary artery disease, or caloric restriction for those with obesity, may prompt excessively restrictive eating patterns that risk exacerbating micronutrient deficiencies and inadequacy of protein-calorie intake. To date, improvements in dietary quality rather than restrictive dietary counseling have shown benefits in primary and secondary CVD prevention,$^{98,99}$ with restrictive approaches to HF sodium or fluid intake not yielding clear outcome benefits$^{97,100}$ and small studies suggesting

CLIMICAL STATEMENTS AND BUDIENCES

CLUNICAL STATEMENTS AND BUEDELINES

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associations between restrictive diets and undernutrition.$^{101,102}$ Thus, there has been a recent trend toward more permissive dietary education for patients with CVD, with the emphasis of pursuing balanced, nutrient-dense food patterns, in the hope of promoting a more sustainable and healthful approach. Dietary counseling should always be personalized to the specific conditions and meet patients' caloric and micronutrient requirements, and such an ethos may help prevent malnutrition development, although supportive evidence is minimal.$^{103}$

NUTRITIONAL SUPPORT FOR CARDIAC INPATIENTS

The EFFORT study (Effect of Early Nutritional Support on Frailty, Functional Outcomes and Recovery of Malnourished Medical Inpatients) highlighted the potential value of individualized nutritional support provided by registered dietitian nutritionists (RDNs) for hospitalized patients.$^{104}$ The EFFORT study was a large, multi-center, randomized controlled trial conducted in 8 Swiss hospitals to evaluate whether individualized nutritional support improves outcomes in hospitalized adults with elevated malnutrition risk, as indicated by a Nutritional Risk Screening 2002 score ≥3 and anticipated length of stay ≥4 days.$^{104}$ Participants were randomized to receive either RDN protocol-guided individualized nutritional support (targeting energy, protein, and micronutrient goals) or standard hospital food with no dietary counseling. Individualized nutritional support significantly reduced the risk of adverse clinical outcomes (composite of mortality, intensive care unit [ICU] admission, readmission, major complications, and functional decline) at 30 days (adjusted odds ratio, 0.79 [95% CI, 0.64–0.97]; P=0.023) and reduced 30-day mortality (adjusted odds ratio, 0.65 [95% CI, 0.47–0.91]; P=0.011) compared with standard care. A post hoc analysis of participants with chronic HF demonstrated that the group receiving RDN-led deployment of tailored nutritional interventions experienced lower 30-day mortality (odds ratio, 0.44 [95% CI, 0.26-0.75]; P=0.002), with a particularly marked effect among patients with highest risk as per the Nutritional Risk Screening tool.$^{105}$ The results underscore the potential benefits of personalized nutritional plans during hospitalizations, although this trial was not designed specifically for patients with CVDs and thus a future clinical trial of a cardiac-specific inpatient nutritional intervention in patients at high malnutrition risk would be important to define the efficacy of this short-term inpatient approach.

Micronutrient insufficiencies, particularly water-soluble vitamin B₃ (thiamine) deficiency in those receiving high-dose loop diuretics, can become prevalent in cardiac inpatients. Inadequate micronutrient intake has been associated with higher mortality and cardiovascular

events in patients with HF.$^{106,107}$ It remains controversial as to whether thiamine deficiency can exacerbate HF symptoms, and supplementation studies suggesting improvements in cardiac function or symptom status are small and of poor quality.$^{108-110}$ Vitamin E, folate, or selenium supplementation has minimal evidence as interventions to improve cardiac stability.$^{111}$ Coenzyme Q10 supplementation has limited clinical trial support in patients with HF but has not been routinely adopted.$^{112}$ Laboratory assessment and supplementation of magnesium and potassium is commonly performed, especially for inpatients undergoing diuresis, but the value of measuring and repleting other micronutrients does not have evidence as standard of care for hospitalized patients with CVD.

There are several methods for estimating patients' energy needs during an acute cardiac illness, including indirect calorimetry with a metabolic cart and predictive equations. The Academy of Nutrition and Dietetics recommends indirect calorimetry as the most accurate and ideal way to assess an individual's resting metabolic rate. Indirect calorimetry is a noninvasive method used to estimate energy expenditure through measurement of oxygen consumption (Vo₂) and carbon dioxide production (VoCo₂). The ratio of VoCo₂ to Vo₂ at the cellular level is the respiratory quotient; because measurement of the respiratory quotient is not easily achieved, an indirect measurement is obtained as the respiratory exchange ratio, which reflects the relative utilization of carbohydrates and føts for energy. An respiratory exchange ratio of 0.7 suggests predominant fat oxidation, whereas 1.0 indicates carbohydrate utilization. The metabolic cart performs indirect calorimetry by capturing and analyzing inhaled and exhaled gases through a canopy or ventilator circuit. The resting energy expenditure (kilocalories per day) is derived from Vo₂ and Vco₂ with the Weir formula: [3.94×Vco₂ (L/min)] + 1.11×Vco₂ (L/min)] × 1440.$^{113}$ This calculation provides a patient-specific estimate of daily caloric requirements, which can guide tailored nutrition support, particularly in critically ill or metabolically complex individuals. However, indirect calorimetry is resource intensive and not easily available in all settings, leading to predictive equations being the most frequently used clinical method (Supplemental Table).

Dietary protein is generally considered a major determinant of muscle mass,$^{118}$ but it is controversial whether enhanced dietary macronutrient intake can overcome the inflammatory catabolic metabolism of advanced cardiac conditions and achieve net gains in fat-free mass.$^{119,120}$ Protein intake goals for patients with CVD have sparse evidence, but the general adult recommendation for 0.8 g·kg⁻$^{1}$·d⁻$^{1}$ may be insufficient for many inpatients with active cardiac disease. Small protein turnover studies in patients with HF suggest that at least 1.1 g·kg⁻$^{1}$·d⁻$^{1}$ may be beneficial,$^{121}$ which has formed the basis of recommendations for patients with HF who develop muscle

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wasting or are at risk of wasting.$^{111,122}$ There are, however, safety concerns about augmenting dietary protein above the 0.8 g·kg$^{-1}$·d$^{-1}$ range, especially from animal sources, because of concerns of accelerating coronary artery disease and HF incidence, as well as the potential for accelerating CKD progression.$^{123-125}$ In the MDRD study (Modification of Diet in Renal Disease), a dietary protein target of 0.6 g·kg$^{-1}$·d$^{-1}$ appeared to limit progression of CKD, at least during the 6-year follow-up time frame.$^{125,126}$ Therefore, current practice favors that adults with mild CKD (stages 1 and 2) should avoid >1.30 g·kg$^{-1}$·d$^{-1}$ protein intake and patients with CKD stages 3 to 5 not on dialysis are recommended to limit to 0.60 to 0.80 g·kg$^{-1}$·d$^{-1}$.$^{127}$ However, in a more recent observational study, there were neutral or inverse associations between protein intake up to 1.6 g·kg$^{-1}$·d$^{-1}$ and mortality among patients with CKD stages 3 to 5 not on dialysis.$^{128}$ The protein requirements of patients with CKD and a concurrent acute cardiovascular condition are not currently defined. In patients receiving maintenance dialysis, protein requirements may be closer to 1.2 to 1.3 g·kg$^{-1}$·d$^{-1}$⁻$^{112}$ as a result of dialysis-related protein loss and systemic inflammation.

To enhance micronutrient and macronutrient dietary sufficiency in hospitals, practical measures include offering nutrient-dense, heart-healthy meals that adhere to established dietary patterns such as DASH or Mediterrane niets. Macronutrient supplementation is increasingly commercially available through protein-calorie-dense shakes, puddings, or bars and is appropriate for inpatients screening positive for moderate or severe malnutrition. In addition, integrating nutrition education and counseling into the care plan can empower patients to make informed dietary choices after discharge. Another potential threat to adequate macronutrient intake for patients with cardiac conditions is NPO orders, often used in preparation for procedures or because of concern for aspiration risks. Although not specifically studied in this population, proactive efforts for individual patients and system-wide efforts to minimize the duration of NPO status may help to ensure timely nutritional intake. Clear liquids or enteral nutrition (EN) should be considered when full oral intake is not feasible to prevent nutritional deficits and to support recovery.

Engaging patients and stakeholders in the nutritional care process is crucial for success, and availability of inpatient RDNs is essential. Providing culturally appropriate meal options can enhance patient satisfaction and adherence to dietary recommendations. Hospitals should capitalize on the opportunity to educate patients about heart-healthy choices, tailoring advice to align with their cultural preferences and being mindful of previous dietary habits. Involving patients in meal planning and offering practical guidance can foster a supportive environment, encouraging long-term adherence to heart-healthy diets.

NUTRITIONAL SUPPORT FOR CARDIAC CRITICAL CARE INPATIENTS

Nutritional support plays a key role in the cardiac ICU (CICU), where malnutrition is frequently encountered.$^{19}$ Although most of the data come from patients with $HF^{90,130,131}$ the critical ill cardiac patient has several factors to consider, including their limited cardiopulmonary reserve, fluid status, and use of vasopressors, mechanical ventilation (MV), or mechanical circulatory support, as well as frequent exposure to NPO requirements.$^{19}$ Moreover, their higher metabolic demand increases cardiac cachexia and sarcopenia risks, often coexisting with malnutrition and frailty, which negatively affects outcomes.$^{19,90}$

General Principles

Modifying nutritional support according to patient characteristics is paramount. In a clinical trial of inpatients with HF (12.5% receiving inotropes) and malnutrition,$^{132}$ an individualized nutritional approach improved mortality and readmissions. Nutritional support in the CICU should consider timing, route, and caloric, fluid, electrolyte, and protein targets and monitor closely for intestinal intolerance, hyperglycemia, or refeeding syndrome. Refeeding syndrome can occur after prolonged starvation with aggressive oral feeding, EN, or parenteral nutrition (PN), and patients with mental health and substance use disorders, malabsorptive syndromes, surgeries, or vomiting are particularly at risk,$^{133}$ A sudden rise in serum glucose levels stimulates insulin release, which drives intracellular phosphorus and potassium levels, resulting in hypophosphatemia and hypokalemia. Refeeding syndrome can be prevented by initiating 40% to 50% of the caloric goal, followed by slow uptitration of caloric delivery over 3 to 4 days, adequate supplementation of thiamine (eg, 100–200 mg IV daily for 5–7 days plus an oral/enteral multivitamin), and frequent monitoring and supplementation of serum electrolytes, including phosphorus.$^{133}$

Given the limited CICU-specific data, ICU nutritional support principles are generally applied to critically ill cardiac patients.$^{134}$ These include initiation of feeding within 48 hours of hospitalization, preferable through EN (Figure 1).$^{135}$ EN is more cost-effective; has lower rates of infection, overfeeding, and hyperglycemia compared with PN$^{19}$,$^{134}$,$^{135}$; and can decrease mortality,$^{134}$,$^{136}$,$^{137}$ enhance immunity,$^{138}$ and decrease duration of MV and ICU stay. PN is reserved for patients with severe gastrointestinal dysfunction$^{135}$ or to supplement nutrition when EN is con-traindicated or limited by gastric function, in the setting of high pressor doses that preclude adequate intestinal perfusion, or when EN is insufficient to achieve at least 70% of the nutritional targets after the first week.$^{134}$,$^{139}$ PN is occasionally started earlier than 1 week if the patient is severely malnourished. Even in patients who

CLIMICAL STATEMENTS AND GUIDEINES AND GUIDEINES

CLIMAL STATEMENTS AND DEJUÈIENS

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![graph TD\n A1[Transition of Care: Admission] --> A2[CICU]\n A2 --> A3[ (+/- procedures)]\n A3 --> A4[Wards]\n A4 --> A5[Discharge]\n A5 --> A6[Outpatient follow-up]\n](1/parseimages/figure1e282db983c44d31898a58fb6192e6d8_0_3.png) Figure 1. Summary of nutritional strategies for patients with cardiovascular conditions across the domains of care.

CICU indicates cardiac intensive care unit; CONUT, Controlling Nutritional Status; CS, cardiogenic shock; ECPR, extracorporeal cardiopulmonary resuscitation; EN, enteral nutrition; GNRI, Geriatric Nutritional Risk Index; HD, hemodynamic; MNA, Mini Nutritional Assessment; mNUTRIC, modified Nutrition Risk in the Critically III; MUST, Malnutrition Universal Screening Tool; NPQ, nil per os; NRS, Nutritional Risk Screening; PNI, Prognostic Nutritional Index; RD, registered dietitian; SNAQ, Short Nutritional Assessment Questionnaire; and TPN, total parenteral nutrition.

are unable to start full EN by 48 hours, it is reasonable to initiate trophic (low) doses of tube feedings (10–20 mL/h) with hypocaloric targets (50–70% of daily expenditure) that aim to stimulate the gut. The infectious risks associated with PN are not specifically quantified for the CICU population, but a large meta-analysis recently compared the complication rates between recipients of PN and recipients of other nutritional strategies among hospitalized patients. When 37 randomized controlled trials investigating PN compared with any other comparator were evaluated, there was an increased risk of infection at any site (relative risk, 1.23 [95% CI, 1.12–1.36]), but mortality was equivalent between the 2 groups.$^{140}$ Best practices include placing a new central venous catheter for the PN infusion and not accessing it for other infusions or blood draws.

The European Society for Clinical Nutrition and Metabolism$^{135}$ recommends a more aggressive approach with early initiation of EN based on recent evidence$^{139}$ compared with the more conservative approach of ASPEN.$^{134}$ After EN initiation, clinicians should monitor for abdominal distention or discomfort, nausea, vomiting, or diarrhea as signs of bowel ischemia. If this occurs, EN should be stopped or feeding rate reduced because mesenteric ischemia carries a mortality exceeding 75%.$^{141}$ Poor tolerance of EN can be due to higher fat and higher fiber formulations, which are often problematic for critically ill patients. In patients with impaired gastric motility, prokinetic agents may be considered, although they are often limited by QT prolongation. Peptide-based enteral formulas contain proteins that have been hydrolyzed to dipeptides and tripeptides, which can be combined with

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higher medium-chain triglycerides to aid absorption. Alternatively, postpyloric tube feedings may be used,$^{134}$ although this approach has not been specifically evaluated in the CICU. Routine monitoring of gastric residuals is no longer recommended because it does not decrease aspiration risk and can result in underfeeding.$^{134,142-144}$

Protein intake goals during critical illness remain controversial. Although providing a high-protein supplementation may appear logical to overcome sarcopenia, a large trial recruiting mechanically ventilated patients in general ICUs called EFFORT Protein (Effect of Higher Protein Dosing in Critically III Patients With High Nutritional Risk) (9% with CVD) failed to demonstrate benefits of a high-protein EN regimen (≥2.2 g·kg⁻$^{1}$·d⁻$^{1}$) versus ≤1.2 g·kg⁻$^{1}$·d⁻$^{1}$) in time to discharge alive from hospital up to 60 days but demonstrated higher mortality in patients with renal failure.$^{145}$ Similarly, the recent PRE-CISe trial (Protein Provision in Critical Illness) assessed higher enteral protein intake (2.0 g·kg⁻$^{1}$·d⁻$^{1}$) compared with standard enteral protein intake (1.3 g·kg⁻$^{1}$·d⁻$^{1}$) in critically ill patients with MV (one-quarter hospitalized for CVD) and evaluated quality of life at 180 days after randomization. The EQ-5D-5L health utility score was lower in patients in the high-protein group; there was also more gastrointestinal intolerance of the higher protein EN.$^{146}$ Another ICU study (40% with HF, 8% with cardiac arrest) compared high-protein nutrition (target energy, 20 kcal·kg⁻$^{1}$·d⁻$^{1}$); protein, 0.9 g·kg⁻$^{1}$·d⁻$^{1}$; protein, 1.8 g·kg⁻$^{1}$·d⁻$^{1}$) with medium-protein nutrition (target energy, 20 kcal·kg⁻$^{1}$·d⁻$^{1}$; protein, 0.9 g·kg⁻$^{1}$·d⁻$^{1}$) and showed less femoral muscle volume loss by computed tomography in the high-protein group but only during a period of electric muscle stimulation.$^{147}$ At the present time, the most appropriate protein intake approaches for the CICU population are likely those in alignment with evidence-based guidance from ASPEN and the Society of Critical Care Medicine, which favor individualized protein intake targets within the 1.2– to 2.0-gkg⁻$^{1}$·d⁻$^{1}$ range, with cautious consideration of higher intake in select patients with burns, trauma, or obesity.$^{148-150}$

Nutritional Support in HF and Cardiogenic Shock in the CICU

Patients admitted with HF to the CICU often have poor nutrient absorption from mucosal edema, low cardiac output, inflammation, and neurohormonal activation with mesenteric vasoconstriction and microvascular dysfunction.$^{19}$ During cardiogenic shock (CS), these effects are further exacerbated by intestinal venous congestion and pressor use, especially vasopressin, which has a particularly unfavorable impact on mesenteric blood flow.$^{151}$ In these scenarios, the initiation of EN may prompt mesenteric ischemia due to increased metabolic demand of the intestinal mucosa.$^{152,153}$ This can occur despite an observed increase in the mesenteric blood because

arteriovenous oxygen extraction in the gut is often impaired in shock states. Accordingly, it may be reasonable to delay EN in patients with worsening CS, uncontrolled acidosis or hypoxemia, gastrointestinal bleeding, nausea, or vomiting.

Although there are no studies specific to CS, 2 trials have evaluated nutritional support in shock. The first study compared early normocaloric EN with PN in shock, including 20% with CS,$^{154}$ showing no differences in survival. There were more complications associated with EN, including bowel ischemia, nausea, diarrhea, and acute colonic pseudo-obstruction. Another trial compared patients with shock receiving early (<24 hours) low-calorie (6 kcal·kg$^{-1}$·d$^{-1}$), low-protein (0.2–0.4 g/kg) EN with those receiving normocaloric (20–25 kcal·kg$^{-1}$·d$^{-1}$), normoproteic (1.0–1.3 g/kg) EN, including ≈18% with CS.$^{155}$ In this study, calorie and protein restriction did not affect survival but was associated with lower complications, including less bowel ischemia and liver disease, and with shorter ICU stay.$^{156}$

EN is not contrained during low-dose vasopres- s administration, and the benefits of early versus late EN have been seen in patients receiving low to moderate vasopressor dosing.$^{159}$ Standard clinical practice in CS is that EN initiation is reasonable once hemodynamic sta- bility is achieved, when vasopressors are no longer being titrated or used in high doses. Although the dose thresh- old for safe vasopressor use during EN is not definite, the mean and maximal tolerated doses of norepinephrine for safe EN feeding in 1 study were 7 and 12.5 µg/min, respectively.$^{158}$ In addition, the risk of intestinal isch- emia is higher for lactate >2.0$^{159}$ or Sequential Organ Failure Assessment score >11.$^{154}$ This more aggressive approach of early EN initiation aligns with recommen- dations from the European Society for Clinical Nutrition and Metabolism$^{135}$ and differs from ASPEN recommen- dations, which suggest delaying EN until appropriate resuscitation is achieved.$^{134}$

Early EN has also been shown to be safe in a prospective observational study with >200 patients with mechanical circulatory support,$^{160}$ although that study excluded patients with refractory CS. However, advanced mechanical circulatory support such as venoarterial extracorporeal membrane oxygenation carries a significantly higher risk of mesenteric ischemia, as high as 5% to 9%,$^{19,161}$ in contrast to 1% to 2% when vasoactive agents alone are used.$^{158}$ Risk factors for mesenteric ischemia in venoarterial extracorporeal membrane oxygenation have included renal replacement therapy and higher vasopressor dosing but not timing or route of nutritional support.$^{162}$ Although early EN in venoarterial extracorporeal membrane oxygenation is associated with lower mortality,$^{163}$ it may be appropriate to delay EN after venoarterial extracorporeal membrane oxygenation and use hypocaloric targets (<70%–80%) and higher protein administration for the hypercatabolic state to

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optimize survival.$^{164,165}$ Indirect calorimetry may become inaccurate during ECMO support,$^{166,167}$ and entrapment of micronutrients and macronutrients in the ECMO membrane can occur.$^{168}$

An additional CICU consideration is use of intravenous lipid emulsions from propofol, clevidipine, or PN.$^{169}$ Propofol provides 1.1 kcal/mL and clevidipine provides 2 kcal/mL; at high rates, these infusions can deliver significant calories, and tube feeding should be adjusted accordingly. For patients receiving PN, ≈30% of calories should come from lipids.$^{148}$ A small benefit is shown in critical care patients from using alternative intravenous lipid emulsions that contain more omega 3 fatty acids than purely soybean oil lipid emulsion, which is higher in omega 6. Overall, lipid emulsion choice may be dictated by product availability and possible allergies, and lipid emulsion should be stopped if triglycerides are >400 mg/dL.$^{148}$

Last, because respiratory failure is the most common critical care indication for CICU admission,$^{170}$ with many patients requiring MV,$^{171}$ it is important to incorporate insensible losses, metabolic demands, and appropriate perietuation management into their nutritional support. Although there is paucity of data in this area, 1 trial including 30% of patients with HF and 2% with CS demonstrated that EN continuation during MV liberation was associated with shorter extubation times, shorter MV duration, better achievement of caloric goals, lower mortality, and less hypoglycemia without differences in aspiration events compared with EN interruption.$^{155}$ This strategy, however, has not been evaluated in the CICU population.

Nutritional Support in Cardiac Arrest in the CICU

In contrast to patients with HF, BMI and nutritional risk scores do not predict outcomes after cardiac arrest.$^{172,173}$ Prior recommendations suggested delaying EN in patients after cardiac arrest on the presumption of lower metabolic rates and delayed gastric emptying, particularly when targeted temperature management at 32°C to 36°C is used.$^{19}$ However, this practice has changed as the use of targeted temperature management has evolved, and newer data demonstrated no difference in complications with early EN (<48 hours) even during targeted temperature management.$^{19,174-177}$ Moreover, early EN may be associated with potential benefits in neurological outcomes and infectious complications after cardiac arrest,$^{176,178}$ although this association may not apply to patients with refractory cardiac arrest undergoing extracorporeal cardiopulmonary resuscitation. In those cases, delayed EN (>48 hours) may be associated with better neurological outcomes,$^{161}$ but this may simply reflect an immortal time bias.$^{179}$

NUTRITIONAL SUPPORT FOR PATIENTS UNDERGOING CARDIAC PROCEDURES

Cardiac Catheterization and Implantable Electronic Device Procedures

Evidence supporting prolonged preprocedural fasting for cardiac catheterization or implantation of electronic devices is weak, with no difference in gastric pH or volume between fasting 2 to 4 hours versus >4 hours.$^{180,181}$ Recently, small randomized studies of patients undergoing routine cardiac procedures requiring conscious sedation have suggested no differences in adverse procedural events for patients who fasted or did not fast before their procedures. In the investigator-initiated SCOFF trial (Safety and Care of No Fasting Prior to Catheterization Laboratory Procedures), patients were randomized 1:1 to preprocedural fasting, meaning no solid food for 6 hours and no clear liquids for 2 hours, or no fasting (patients were encouraged to have regular meals). The primary composite end point of hypotension, aspiration pneumonia, hyperglycemia, and hypoglycemia occurred in 19.1% of the fasting group and 2.0% of the no-fasting group, with the analyses confirming noninferiority of no fasting (based on a noninferiority margin of 3% and a likelihood of 99.1%).$^{182}$ Patient satisfaction was significantly greater in the no-fasting group. Together with data from other similar studies,$^{183,184}$ there is an increasing movement toward removing NPO requirements for diagnostic cardiac catheterization cases and routine device procedures, which has the potential to decrease in-hospital malnutri- tion development.

Cardiac Surgery

Patients classified as malnourished by GLIM criteria have poorer surgical outcomes, with a complication rate of 65.9% compared with 49.7% for those not classified as malnourished.$^{185}$ According to Enhanced Recovery After Surgery recommendations,$^{186}$ perioperative nutritional optimization is key to expediting recovery. This includes preoperative malnutrition assessment with validated tools (Table 3) to predict postoperative complications$^{187}$ and clinical, biochemical, and imaging parameters, for example, quadriceps ultrasound or computed tomography, to assess for sarcopenia.$^{188}$ Although not good markers of nutritional status, albumin <3.0 g/dL and prealbumin ≤20 mg/dL have been used as acute-phase markers to trigger nutritional supplementation within 1 week of surgery.$^{186,189-191}$

Minimizing starvation to prevent iatrogenic malnutrition is key preoperatively.$^{192}$ European recommendations have adopted evidence for clear liquids up to 2 hours before and a light meal up to 6 hours before surgery.$^{180,188,193}$ Although preoperative oral carbohydrate loading has been proposed to benefit cardiac function and may improve length of stay, its evidence before cardiac surgery is weak.$^{186,194}$

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During the postoperative period, nutritional support with EN is preferable over PN and should be initiated within 48 hours or within 24 hours if malnutrition present.$^{195}$ It is recommended to start with hypocaloric EN, with 80% of the target protein and caloric goals, considering supplemental PN if necessary.$^{188}$ As with patients with CS, for patients after cardiotomy who remain hemodynamically unstable, requiring vasopressors or mechanical circulatory support, delaying EN may be appropriate given that the risk of intestinal infarction and bacterial translocation with resulting sepsis is elevated.$^{196,197}$ In these cases, delaying EN may be appropriate.$^{198}$ If EN cannot be started by day 7, PN is indicated.

NUTRITIONAL SUPPORT AFTER DISCHARGE AND READMISSION REDUCTION

Several small but randomized studies highlight the importance of nutritional interventions in reducing cardiac readmissions, specifically in patients with HF. The PICNIC (Programa de IntervenCión Nutricional en pacientes hospitalizados por Insuficiencia Cardiaca desnutridos) study recruited patients in Spain with HF and risk of malnutrition. Individualized RDN-led dietary counseling and support reduced the composite of hospital readmissions and mortality, as well as mortality as a secondary end point, and improved quality of life.$^{132}$ The next steps would ideally include a similar protocol for postdischarge patients with HF in the United States, with expansion to patients with other CVDs if effective in reducing HF re-dmissions. Definitive data on malnutrition interventions specifically for patients after myocardial infarction or coronary interventions are not currently available.

GOURMET-HF (Geriatric Out-of-Hospital Randomized Meal Trial in Heart Failure) examined the impact of a tailored DASH diet after HF discharge and found a trend toward improved HF readmissions and mortality,$^{199}$ although this was predominantly a sodium-restriction intervention and not a malnutrition intervention. Medically tailored meals (MTMs) based on the DASH pattern were prepared, packaged for refrigerator storage, and home delivered once weekly. Potassium content was modified from 4500 to 3000 mg/d in patients with estimated glomerular filtration rate <45 mL·min$^{-1}$·1.73 m$^{-2}$, or 45 to 60 mL·min$^{-1}$·1.73 m$^{-2}$ with serum potassium >4.5 mmol/L, or potassium >4.5 mmol/L with potassium-sparing diuretic use. A follow-up study, GOURMET-VA (Geriatric Out-of-Hospital Randomized Meal Trial in Heart Failure: Veterans Affairs; NCT05996328) will enroll a larger cohort to define the efficacy and safety of nutritional support in the postdischarge HF setting.

The concept of MTMs is gaining traction, particularly within the Food Is Medicine movement. MTMs provide patients with meals designed to meet their specific

medical and nutritional needs, particularly for those with chronic conditions such as CVD. Although some general medical programs have reported neutral results for Food Is Medicine interventions,$^{200,201}$ the overall evidence base suggests potential benefits for cardiovascular health and readmission reduction. MTMs can help bridge the gap between inpatient dietary recommendations and practical, daily nutrition after discharge, supporting better health outcomes for patients with CVD. Cardiac rehabilitation offers a prime opportunity to integrate high-quality nutritional counseling into cardiovascular outpatient care. This setting allows comprehensive lifestyle interventions, including dietary education, tailored to the needs of patients with CVD. Effective nutritional counseling during cardiac rehabilitation can enhance patients' dietary habits, support recovery, and prevent future cardiac events. However, achieving these benefits may require additional training for clinicians to ensure that they are equipped to provide evidence-based nutritional advice. Investing in clinician education on nutrition can strengthen the impact of cardiac rehabilitation programs and improve patient outcomes. There are significant potential opportunities to study integrated nutritional support both during hospitalization and early after discharge, leveraging initiatives such as MTMs and comprehensive cardiac rehabilitation to determine the scope to enhance outcomes for patients with CVD.

RDNs AS KEY MEMBERS OF THE CARDIAC CARE TEAM

Every patient admitted to the CICU should undergo comprehensive nutritional assessment, including physical examination and laboratory parameters; evaluation for cardiac cachexia, sarcopenia, and risk of refeeding syndrome; and specific volume and electrolyte goals. Certain nutritional risk scores previously validated in CICU conditions,$^{202}$ including Controlling Nutritional Status, Prognostic Nutritional Index, Geriatric Nutritional Risk Index, Subjective Global Assessment, and modified Nutrition Risk in the Critically III, can provide useful information outlined in Table 2.$^{19}$ This comprehensive and tailored evaluation is best performed by RDNs because they play a pivotal role in identifying and classifying malnutrition; optimizing and individualizing nutritional support,$^{203,204}$ including determination of appropriate micronutrient and macronutrient supplementation; and assessing and adjusting calric, protein, and fluid administration. RDNs also provide key roles in nutrition education, counseling discharge planning for patients and families,$^{205}$ and longitudinal follow-up for dynamic targets. Suggested criteria for identification of inpatients who may benefit from RDN assessment and counseling are provided in Figure 2.

Unfortunately, despite increasing implementation of interdisciplinary teams in the CICU,$^{206,207}$ the RDN role

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CLINUAL STATEMENTS AND EVIDELINES

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![graph TD\n A1[Screening for cardiovascular inpatients at higher risk of malnutrition or cachexia Suggested criteria for RDN inpatient consultation: • BMI <20 or ≥30 kg/m2 or unintentional edema-free weight loss >7.5% in prior 6-12 months • Patients reporting <50% prior nutritional intake or identified as at risk of malnutrition on a nursing-administered screening tool eg, SNAQ, MNA-SF, MST or MUST scores • Diabetes or chronic kidney disease • History of malabsorption or bariatric surgery • Cardiogenic shock or other CICU admission • Consideration for heart transplantation or mechanical circulatory support • Receiving/considered for enteral or parenteral nutrition during the hospitalization • Hospitalized ≥7 days] --> A2[Initial RDN evaluation should include: Medical/surgical, diet, weight and social histories, at least 24-hour food and supplement intake Malnutrition diagnosis is made: The diagnosis, etiology categorization and severity grading is completed as per ASPEN/AND Consensus Characteristics of Adult Malnutrition Initial RDN counseling should include: Heart-healthy diet composition, recommendations on protein and calorie intake goals, consideration of any need for sodium restriction, interventions for specific problems identified including oral dietary supplementation, consideration of enteral or parenteral nutrition for patients meeting these indications]\n A2 --> A3[Treatment of Malnutrition • RDN develops individualized nutrition plan with patient, caregivers, clinicians; may include protein-calorie supplementation for at least 1.1 g/kg/day protein, calories per predictive equation or indirect calorimetry • RDN reassessment q 3–4 days for high-risk and 7 days for moderate-risk inpatients • Consideration of enteral or parenteral nutrition options, as per standard inpatient recommendations • If initial dietary/weight gain goals not met during inpatient reassessment, reconsideration of enteral or parenteral nutrition options]\n A2 --> A4[Treatment of Cachexia • RDN develops individualized nutrition plan with patient, caregivers, clinicians; may include protein-calorie supplementation for at least 1.1 g/kg/day protein and specific weight gain goals • RDN reassessment q 3–7 days for inpatients, or 4–12 weeks for outpatients • If dietary/weight gain goals not met, consideration of appetite stimulants or protein supplementation options • If meeting sarcopenia criteria and physically able, consider referral for graded exercise • Cachexia best addressed by effectively treating underlying medical condition]\n A2 --> A5[Additional Services • RDN, or other health professional with specialist nutrition knowledge, remains a resource to enhance optimal dietary composition • Access to postdischarge medically tailored meals if indicated, or services to reduce food insecurity if this is contributory • Ideally, annual nutrition reevaluation as above]\n](1/parseimages/figure0c44ea936304414b9d7f1378f5bf3426_0_3.png) Figure 2. Practical guidance for the screening, evaluation, and treatment of cardiovascular in patients at risk of malnutrition or cachexia.

ASPEN/AND indicates American Society for Parenteral and Enteral Nutrition/Academy of Nutrition and Dietetics; BMI, body mass index; CICU, cardiovascular intensive care unit; MNA-SF, Mini Nutritional Assessment Short Form; MST, Malnutrition Screening Tool; MUST, Malnutrition Universal Screening Tool; RDN, Registered Dietitian Nutritionist; and SNAQ, Short Nutritional Assessment Questionnaire. Adapted from Vest et al.$^{111}$ Copyright © 2019, with permission from Elsevier Inc.

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does not always receive prioritization and may remain underused. To date, no studies have evaluated the impact of RDNs on outcomes in the CICU,$^{202}$ and research in this area should be prioritized. Furthermore, the availability of RDNs with expertise in acute cardiovascular conditions is limited, highlighting the need to promote training and staffing models to enhance the RDN workforce and to support their role educating and working alongside clinical teams managing patients with acute cardiac care needs.

UNANSWERED QUESTIONS IN THE MANAGEMENT OF MALNUTRITION AND CACHEXIA IN PATIENTS WITH CARDIAC CONDITIONS

Multiple knowledge gaps exist and should serve as research priorities for defining best practices for preventing,

screening for, and managing malnutrition and unintentional weight loss in hospitalized adults with CVD (Figure 3).$^{211}$ª First, there is a lack of consensus on which validated malnutrition tool is most appropriate for cardiac inpatients, both for malnutrition detection and for prediction of mortality and readmission, with recognition that performance may differ by disease state and severity of illness (Table 2).

Once hospitalized patients with or at risk of malnutrition are identified, the optimal strategy for assessing body composition to diagnose cachexia and sarcopenia is unknown. Choice of diagnostic tool is based largely on cost, availability, influence of volume status, ease of use, and overall body habitus.$^{212}$,$^{213}$ Although DXA is a rapid, inexpensive method to evaluate for sarcopenia, it is ionizing and nonportable, limiting accessibility for inpatients.$^{90}$,$^{212}$,$^{214}$ Similarly, bioelectrical impedance analysis and bioelectrical impedance spectroscopy are low-cost,

![graph TD\n A1[Randomized Controlled Trials/Research] --> A2[Mechanistic]\n A1 --> A3[Screening and Diagnosis]\n A1 --> A4[Nutritional Interventions]\n A1 --> A5[Pharmacologic Interventions]\n A2 --> A6[Do mechanisms of malnutrition differ by the type and acuity of the CV condition(s)?\nHow do we manage the obesity/cachexia paradox in patients with HF?\nWhat role do environmental, genomic, epigenomic, and microbiome variations play in the development and management of malnutrition and cachexia?]\n A3 --> A7[Are there standard definitions for malnutrition, cachexia, and sarcopenia?\nWhat is the best approach to identify patients with or at risk for malnutrition and cachexia? Which screening tool(s) is best? Can technology(decision support, AI) help?\nWhat diagnostic method(s) are best for measuring body composition to diagnose cachexia and sarcopenia?\nHave the screening and diagnostic methods been validated in hospitalized and critically ill patients with CV disease?]\n A4 --> A8[What is the best method for assessing nutritional needs for hospitalized patients with CV disease?\nShould interventions focus on specific deficiencies of micronutrients, generalized nutrition plans(eg, focused on macronutrients, enteral/parenteral nutrition), or“diets”(eg, DASH/DASH-SRD, Mediterranean)?\nShould targeted caloric goals differ based on the type, acuity, and severity of the CV condition(s)?\nWhat are the risks/benefits of parenteral nutrition in patients with CV disease unable to achieve enteral nutrition targets?\nDoes or will precision nutrition have a role in managing malnutrition and cachexia in patients with CV disease?\nIs rehabilitation effective in preventing malnutrition and cachexia in patients with CV disease?]\n A5 --> A9[Do specific therapies(eg, medications, devices, transplantation) increase or mitigate nutritional risk?\nWhat role do currently approved medications(eg, anabolic steroids, appetite stimulants, anti-inflammatory drugs, antioxidants) have in the management of malnutrition and cachexia in patients with CV disease?\nWhat investigational drugs or drug targets are promising for the management of malnutrition and cachexia in patients with CV disease?]\n](1/parseimages/figuree0a48b2ace424ed3b9a3f90b4ae3899f_0_7.png) Al indicates artificial intelligence; CV, cardiovascular; HF, heart failure; DASH, Dietary Approaches to Stop Hypertension; and SRD, sodium-restricted diet. Data from Laimer et al,$^{208}$ Gullett et al,$^{209}$ Johnson et al,$^{210}$ Vest et al,$^{111}$ Kadakia et al,$^{211}$ Ionze et al,$^{90}$ and Watanabe and Miyagoe-Suzuki.$^{211}$a

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|FDA-approved medications||||| |---|---|---|---|---| |Drug class/drug|Mechanism of action|Outcomes|Adverse effects|Comments| |Appetite stimulants:||||| |Megestrol|Unknown|Increase weight gain and fat mass, no increase in LBM|Hypertension, thromboembolism at high doses, edema, palpitations|Not studied in patients with CVD; dose-related effects (range 160-800 mg daily)| |Mirtazapine|May be related to increased leptin concentrations|Increase weight gain and fat mass|Drowsiness, dry mouth, constipation, dizziness, edema|7.5-30 mg at bedtime; drowsiness and dizziness may limit use in older adults| |Cannabinoids|May stimulate orosensory reward pathway|Inconsistent results on appetite, weight gain in cancer-related cachexia|Drowsiness, tachycardia, hypotension, confusion|Dronabinol dose: 2.5-5 mg twice daily; cannabis use may reduce heart transplantation candidacy| |Antiinflammatory:||||| |Omega-3 fatty acids|Decrease inflammation, proinflammatory factors, and proteolytic pathways; increase appetite|Inconclusive|Diarrhea, nausea, belching|1-4 g daily; effects likely dependent on dose, timing, duration, and formulation| |Anabolic agents:||||| |Growth hormone|Stimulates production of IGF-1, leading to protein synthesis and muscle growth|Consistent anabolic effects in patients with malnutrition and catabolic states|Sodium retention, edema|Inconsistent efficacy in patients with HF| |Steroid derivatives:|Bind to cytosolic receptors, increase protein synthesis and muscle mass|Increase weight gain, LBM, and muscle strength; testosterone did not improve exercise capacity or QOL in patients with HF|Fluid retention, increased liver enzymes, decreased HDL-C, drug interaction with warfarin|Testosterone has limited benefit in HF; oxandrolone FDA approval was withdrawn; nandrolone no longer marketed in the United States| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||| |(androlone)|(androlone)|||<start>4<conten|

ActRIIB indicates activin receptor IIB; CVD, cardiovascular disease; EMA, European Medicines Agency; FDA, US Food and Drug Administration; GDF, growth differentiation factor; GFRAL, glial cell-derived neurotrophic factor family receptor α-like; GHD, growth hormone deficiency; HDL-C, high-density lipoprotein cholesterol; HF, heart failure; IGF, insulin-like growth factor; LBM, lean body mass; and OOL, quality of life.

CLIMAL STATEMENTS AND EDEUINES

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|1. Routinely assess nutritional risk in all cardiovascular inpatients.| |---| |Malnutrition is prevalent yet underrecognized in cardiovascular disease, especially in critical care. Use of validated screening tools to detect higher-risk patients should be followed by the use of the Academy of Nutrition and Dietetics and ASPEN diagnostic criteria.| |2. Avoid underfeeding in the CICU. Initiate EN within 24 to 48 of CICU admission for most patients. Hypocor- loric, high-protein feeds can be started in those on low-dose vasopressors, with close hemodynamic monitoring to avoid gut ischemia.| |3. Delay nutrition when hemodynamically unstable. In patients requiring high-dose vasopressors or MCS, delay EN under car- dovascularly stabilizing to reduce the risk of intestinal ischemia. Use PN by day 7 if the enteral route remains contraindicated.| |4. Protein intake requirements are nuanced and require ongoing research. Protein intake goals of 1–12 g·kg$^{-1}$·d$^{-1}$ may be appropriate for patients with cardiac cachexia, and current society guidance for critically ill adults favor the 1.2–2.0 g·kg$^{-1}$·d$^{-1}$ range; studies of higher protein intake >2.0 g·kg$^{-1}$·d$^{-1}$ have not proved beneficial.| |5. Reassess traditional fasting before cardiac procedures. Fasting before elective procedures such as routine cardiac catheterization or device implantation may be unnecessary and could promote malnutrition. It may be appropriate to allow clear liquids up to 2 h and light meals up to 6 h before some surgical procedures.| |6. Integrate nutritional strategies in cardiac surgery pathways. Assess and optimize nutrition preoperatively and consider the use of an Enhanced Recovery After Surgery program pathway. Postoperatively, start enteral nutrition early and consider supplemental parental nutrition if en- teral feeding is not feasible within 7 d.| |7. Address malnutrition to reduce readmissions, especially in HF. Nutritional interventions (eg, tailored diets; RDN counseling) can reduce hospital readmissions and mortality in HF. Studies such as PICNIC and GOURMET-HF highlight the potential impact of individualized dietary sup- port after discharge.| |8. Consider MTMs at discharge. MTMs, aligned with the Food Is Medicine model, offer a scalable interven- tion to support dietary adherence and to reduce cardiovascular readmis- ions after discharge and should focus on accessibility and cultural accept- ability of high-quality foods.| |9. Provide cardiac rehabilitation with nutrition counselling. Cardiac rehabilitation is an underused platform for delivering high-impact dietary education. Embedding RDNs in rehabilitation programs can improve patient adherence to heart-healthy diets and support long-term secondary prevention.| |10. Strengthen the role of RDNs in cardiovascular care. RDNs are essential to providing individualized, evidence-based nutrition therapy across the cardiovascular continuum, from CICU to discharge plan- ning. Their role remains underused, and the workforce remains understaffed. Clinicians and institutions should advocate for greater integration and trin- ing of RDNs in cardiovascular-specific care.| |ASPEN indicates American Society for Parenteral and Enteral Nutrition; CICU, cardiac intensive care unit; EN, enteral nutrition; GOURMET-HF, Geriatric Out- of-Hospital Randomized Meal Trial in Heart Failure; HF, heart failure; MCS, me- chanical circulatory support; MTM, medially tailored meal; PICNIC, Programa de IntervenCión Nutricional en pacientes hospitalizados por Insuficiencia Cardiaca desnutridos; PN, parenteral nutrition; and RDN, registered dietitian nutritionist.| |nonionizing alternatives to DXA. Bioelectrical imped- ance analysis of fat mass shows variability at body com- position extremes for patients with HF compared with|

DXA,$^{215}$ but skeletal muscle mass correlates with absolute peak $Vo_2$ in patients with HF with reduced ejection fraction and obesity.$^{88}$ The use of ultrasound to directly measure skeletal muscle thickness is attractive because it is portable and nonionizing and can be repeated over time. However, ultrasound lacks standardized protocols and thresholds and is operator dependent.$^{216}$ Deuterated creatine dilution is an evolving tool that assesses total body muscle mass by measuring total body creatine pool size, which may be more precise at predicting mortality than DXA.$^{217}$ However, deuterated creatine has not been validated in patients with CVD and is not yet available for routine clinical practice.$^{217,218}$

Unanswered mechanistic questions contribute to uncertainties about the optimal assessment strategies and treatment modalities for malnutrition and cachexia in patients with CVD and warrant further investigation.

Can treatment of underlying CVD reverse cachexia? In patients with HF, this may be possible by improving neurohormonal derangements through guideline-directed medical therapy, implantable devices, and heart transplantation.$^{90}$ There may also be an opportunity for emerging cancer cachexia therapies such as growth differentiation factor-15 inhibition in cardiac cachexia.$^{219}$

How do obesity, weight loss, and body composition affect outcomes for patients with HF? Obesity is a known risk factor for incident HF, yet moderately elevated BMIs may be associated with favorable outcomes in patients with HF (the "obesity paradox") likely as a result of unintentional cachexia-related weight loss in patients with lower BMIs.$^{19,111}$ A similar concern arises with the use of antiobesity medications for patients with HF, in whom lean mass loss may exacerbate functional limitations.$^{220}$

How do environmental factors and individual differences influence the development of malnutrition and response to dietary interventions in patients with CVD? In lieu of universal dietary interventions, precision nutrition may incorporate environmental, genomic, epigenomic, and microphone variations to predict response to diets and to customize dietary interventions in malnourished and cachectic patients with CVD.$^{221}$

High-quality nutritional evidence in acutely and critically ill patients with CVD is currently inadequate and can be challenging to obtain. Because studies of nutritional and activity-based interventions may not attract industry funding, engagement and strategic partnerships from community-based organizations and philanthropic foundations may be more appropriate.$^{105,222,223}$ Enhancing research-focused collaborations with RDNs is crucial, as demonstrated by the EFFORT and PICNIC studies.$^{104,132}$ Although several USD and Drug Administration-approved and investigational medications have been studied to prevent and manage malnutrition and cachexia, their use is largely off-label, and little is known about the safety and efficacy in patients with CVD (Table 4).

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CLUNIAL STATEMENTS AND EUDIENCES

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CONCLUSIONS

Despite multiple areas of incomplete knowledge in the diagnosis and management of malnutrition and cachexia among inpatients with cardiovascular conditions, several principles are now well established (Table 5). The prevalence of malnutrition lies between 20% and 60% in this population, with risk factors including age, comorbidities, metabolic demands, and inflammation and health care factors such as inpatient food choices and NPO times. The GLIM criteria are the cornerstone of malnutrition diagnosis. For stable inpatients, a personalized nutrition plan for patients at risk of malnutrition may improve survival, and the provision of culturally acceptable, nourishing hospital food should be a patient safety goal. For critically ill patients, the risks of undernutrition are high. EN initiation is recommended by 48 hours of admission, provided that any pressor requirement is trending down and end-organ perfusion is sufficient; for patients who do not meet these goals by day 7, PN should be initiated. Although protein goals of 1 to 1.2 g·kg⁻$^{1}$·d⁻$^{1}$ may be appropriate for patients with chronic cardiovascular conditions associated with wasting, higher protein intake targets in the region of >2.0 g·kg⁻$^{1}$·d⁻$^{1}$ have not proved beneficial in patients with MV. Clinical trial data now support the removal of NPO requirements before cardiac catheterization and electronic device implantation procedures under conscious sedation. Increased awareness and education surrounding the risk of malnutrition and practical steps that can be taken to optimize nutritional health will be of benefit to the diverse

populations of patients with CVD admitted to hospital for acute decompensations of their cardiac conditions.

ARTICLE INFORMATION

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on October 27, 2025, and the American Heart Association Executive Committee on December 8, 2025. A copy of the document is available at https://professional.heart.org/state-ments by using either "Search for Guidelines & Statements" or the "Browse by Topic" area. To purchase additional reprints, call 215-356-2721 or email Meredith.Edelman@wolterskuwer.com

The American Heart Association requests that this document be cited as follows: Vest AR, DiDomenico RJ, Lichtenstein L, Slater T, Ekpo E, Damluji AA, Bohula E, Alviar CL; on behalf of the American Heart Association Acute Cardiac Care and General Cardiology Committee of the Council on Clinical Cardiology; and Council on Cardiovascular and Stroke Nursing. Malnutrition and cachexia in inpatients with acute cardiac conditions: a scientific statement from the American Heart Association. Circulation. 2026;153:e······...e····... doi: 10.1161/CIR.000000000001405

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Disclosures

Writing Group Disclosures

|Writing group member|Employment|Research grant|Other research support|Speakers' bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Amanda R Vest|Cleveland Clinic|National Heart, Lung, and Blood Institute (grant R01HL167113); National Center for Advancing Translational Sciences (grant RC2TR004377)|None|None|None|None|None|None| |Carlos L. Alviar|New York University|Baxter Medical*|None|None|None|None|Zoll†; JNJ Medtech*|None| |Erin Bohula|Brigham and Women's Hospital and Harvard Medical School|None|Novo Nordisk†|None|None|None|Novo Nordisk†|None| |Abdulla A. Damluji|Johns Hopkins Medicine Inova Center of Outcomes Research|None|None|None|None|None|None|None|

(Continued)

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Malnutrition and Cachexia in Inpatients With Acute Cardiac Conditions

Writing Group Disclosures Continued

|Writing group member|Employment|Research grant|Other research support|Speakers' bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Robert J. DiDomenico|University of Illinois at Chicago|Society of Critical Care Medicine Carolinas and Virginias Chapter (coinvestigator on a grant surveying pharmacists regarding the use of digoxin in patients receiving continuous renal replacement therapy)*; Consortium of Academic and Research Libraries in Illinois|Support for Creation of Open Educational Resources (c/o Fund for the Improvement of Postsecondary Education) (coinvestigator on grant to support development of an open educational resource book on fundamental pharmacology for nursing students)*; Institute for Clinical and Economic Review (coinvestigator on a grant to conduct a cost-effectiveness analysis of new therapies to treat amyloid transthyretin cardio-myopathy)*; Cook County Department of Public Health (co-principal investigator on a grant to provide health information and screening services to underrepresented communities in suburban Cook County)†; Agency for Healthcare Research & Quality (unpaid member of the DSMB for grant 1R18HS028787-01A1)*|American College of Clinical Pharmacy (chair, Research Affairs Committee [unpaid])*; American College of Clinical Pharmacy (board of regents member)*|None|None|None|None|None| |Eson Ekpo|Scripps Health|None|None|None|None|None|None|None| |Lily Lichtenstein|Tufts Medical Center|None|None|None|None|None|None|None| |Tammy Slater|Johns Hopkins University School of Nursing|None|None|None|None|None|None|None|

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives $5000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.

*Modest.

†Significant.

Reviewer Disclosures

|Reviewer|Employment|Research grant|Other research support|Speakers' bureau/honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Salvatore Carbone|EVMS at Old Dominion University|None|None|None|None|None|None|None| |Elissa Driggin|Columbia University Medical Center/New York-Presbyterian Hospital|None|None|None|None|None|None|None| |Alejandra Gutierrez|University of Minnesota|None|None|None|None|None|None|None| |Onyedika J. Ilonze|Indiana University School of Medicine|None|None|None|None|None|None|None| |Melana Yuzefpolskaya|Columbia University Medical Center|Abbott (Enhanced Nutritional Optimization of Patients Prior to Left Ventricular Assist Device Implantation)*|None|Abbott*|None|None|None|None|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives $5000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.

*Modest.

ALMID STATEMENTS JUMID ALMID STATEMENTS

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Malnutrition with Carex and Inpatients With Acute Cardiac Conditions

REFERENCES

1. White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy Malnuttron Work Group. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Internal Nutrition: characteristics recommended for the identification and documentation of adult malnuttron (undermand). J.P. J. Parenter Enteral Nutr. 2012;36:275-283. doi: 10.1177/0148067112440285 2. Soeters P, Bozzetti F, Cynober L, Forbes A, Shenkin A, Sobotka L. Defin malnutrition: a plea to rethink. Cin Nutr. 2017;36:8906-901: doi: 10.1016/j.clnu.2016.09.032 3. Ferreiro, S. Ferreiro, D. Álvarez Rodríguez L, Otero García Q, P. Pérez Poza M, Antúnez Múnios PJ, Cacho Antonio C, López Pais J, Juskowa M, Cid Álvarez AB, et al. Prognostic impact of change in nutritional risk on mortality and heart failure after transcatheter aortic valve replacement. Circ Cardiovasc Interv. 2021;14:e0093422. doi: 10.1161/CIRCINTERVENTIONS.120.009342 4. Kurmus Ferik O, Akbuga K, Tolunay H, Aslan T, Eren M, Erkan AF, Ekici B, Akgul Eran C, Ekerancioglu C. Poor nutritional status is associated with arrhythmic events on 24-hour Holter recording. Med Princ Pract 2022;31:368-375. doi: 10.1159/000524396 5. Norman K, Hass U, Pirlich M. Malnutrition in older adults: recent advances and remaining challenges. Nutrients. 2021;13:2764. doi: 10.3390/nu13082764 6. Lorente M, Azpiroz MJ, Guedes P, Burgos R, Lluch A, Dos L. Nutrition, detary recommendations, and supplements for patients with congenital heart disease. Int J Cardiol Congenit Heart Dis. 2023;12:100449. doi: 10.1016/j.ijcchd.2023.100449 7. Hirose S, Matsue Y, Kamiya K, Kagiyama N, Hiki M, Dotare T, Sunayama T, Konishi M, Saito H, Saito K, et al. Prevalence and prognostic implications of malnutrition as defined by GLIM criteria in elderly patients with heart failure. In Stair nutr. 2021;40:4334-4340. doi: 10.1016/j.clnu.2021.01.014 8. Cass AR, Charlton KE. Prevalence of hospital-acquired malnutrition and modificable determinants of nutritional deterioration during inpatient admissions: a systematic review of the evidence. J Hum Nutr Diet. 2022;35:1043-1058. doi: 10.1111/jn.13009 9. Lin H, Zhang H, Lin Z, Li X, Kong X, Sun G. Review of nutritional screening and assessment tools and clinical outcomes in heart failure. Heart Fail Rev. 2016;21:549-565. doi: 10.1007/s10741-016-9540-0

10. Liu J, Liu J, Wang J, Yan Z, Li Rang Q, Wang X, Wang Z, Liu M, Luan X. Prevalence and impact of malnutrition on readmission among hospitalized patients with heart failure in China. ESC Heart F,2022;9:4297-4279. doi: 10.1002/feh2f.14152 11. Kawakubo Y, Shirahi Y, Kohsaka S, Kohno T, Goda A, Nagatomo Y, Nehihata Y, Saji M, Takei I, kekami Y, et al. West Tojo Hui� in Failure Reg. I. Potential association with malnutrition and allocation of combination medical therapies in hospitalized heart failure patients with reduced ejection fraction. So Rep. 2022;12:8818. doi: 10.1038/s41598-022-12357-4 12. KaluZona-Oleksy M, Kryszofiak H, Migaj J, Wlekik M, Duchem M, Uchmanowicz I, Lesiak M, Straburzskysm-Migaj E. Relationship between nutritional status and clinical and biochemical parameters in hospitalized patient with heart failure with reduced ejection fraction, with 1-year follow-up. Nutrients. 2020;12:930. doi: 10.3390/nu12082330 13. Weidenhammer A, Prausmueller S, Spinka G, Goliasch G, Arfsten H, Pavo N, Huelsmann M, Bartko P. Malnutrition in patients with chronic heart failure. Eur Heart J, 2023;43:2845(plerr) 23eha544.0106. doi: 10.1039/eurthej/ehac544.1056 14. Lu H, Claggett BL, Minamisawa M, Ostrominski JW, Foa A, Pabon MA, Kalayci A, Vaduganathan M, Cikes M, Shah AM, et al. Prognostic significance of nutritional scores in patients with heart failure: insights from the PRAGAR-ONF-TR. J Am Heart Assoc. 2025;14:e0387827. doi: 10.1161/JAHA.124.038872 15. Minamisawa M, Seidelmann SB, Claggett B, Hegde SM, Shah Am. Desai AS, Lewis EF Shah SJ, Sweitzer NK, Fang JC, et al. Impact of malnutrition using geriatric nutritional risk index in heart failure with preserved ejection fraction. JACC Heart Fail. 2019;7:664-675. doi: 10.1016/j/jchf.2019.04.020 16. Almutawa DA, Almuammar M, Elshafie MM, Aljuraiban GS, Alnafisah A, Abulawmea YM,� 淫阳术 S, Multivaltion status of male and female transport plants based on the Nutritional Risk Index. Nutrients. 2020;12:3868. doi: 10.3390/nu12132868 17. Vest AR, Price LL, Chanda A, Sweigart BA, Chery J, Lawrence M, Parsy L, Gulati G, Kiernan MS, Upshaw JN, et al. Cardiac cachexia in left ventricular assist device recipients and the implications of weight gain early after implantation. J Am Heart Assoc. 2023;12:e029086. doi: 10.1161/JAHA.122:029086

18. Lizancos Castro A, Parada Barcia JA, Abu-Assi E, Cespon Fernandez M, Diaz L, Garcia F, Cabeza M, Dominguez R, Galan A, Torres J, et al. Prevalence and prognostic significance of malnutrition among patients with acute coronary syndrome. Eur Heart J. 2020;41(suppl 2):ehaa946.1797. doi: 10.1093/ehj/cahaa946.1797. doi: 19.1093/ehj/cahacc/zuase018 20. Ni W, Guo K, Shi S, Cheng L, Zhou Y, Zhang F, Xu J, Lin K, Chen C, Gao Z, et al. Prevalence and prognostic value of malnutrition in patients with acute coronary syndrome and chronic kidney disease. Front Nutr. 2023;10:187672. doi: 10.3389/fnut2023.1187672 21. Lai AR, Warrier L, Wirare, Z, Lin C, Chin YH, Kong G, Anand VV, Lee EC, Lai H, Ng HW, et al. Cardiovascular outcomes in acute coronary syndrome and malnutrition: a meta-analysis of nutritional assessment tools. JACC Adv. 2023;2:100635. doi: 10.1016/j.javcad.2023.100635 22. Hosneifi F, Pitcher I, Kang M, MacKay M, Singer J, Lee T, Madden K, Cams J, Wong, G Fordyce C. Association of malnutrition with in-hospital and long-term outcomes among ST-elevation myocardial infarction patients receiving primary PCI. Eu Heart J. 2022;43(suppl 2):ehac544.1421. doi: 10.1093/eurheart/ehac544.1421 23. Asrade M, Shehibo A, Tigabu Z. Magnitude of undernutrition and associated factors among children with cardiac disease at University of Gondar hospital, Ethiopia. BMC Nutr. 2021;7:43. doi: 10.1186/s40795-021-00449-9 24. Zhang Y, Lu L, Yang L, Yan W, Yu Q, Sheng J, Mao X, Feng Y, Tang Q, Cai W, et al. Evaluation of a new digital pediatric malnutrition risk screening tool for hospitalized children with congenital heart disease. BMC Pediatr. 2023;23:126. doi: 10.1186/s12887-023-03899-1 25. Murni IK, Palmasari L, Wirawan MT, Arafuri N, Nurani N, Sativa ER, Nugroho S, Noormanto N. Outcome and factors associated with undernutrition among children with congenital heart disease. PLoS One. 2023;18:e0281753. doi: 10.1371/journal.pone.0281753 26. Cespon Fernandez M, Abou-Assi E, Lizancos Castro A, Parada Barcia JA, Baraneiro Pardal C, Melendo Viu M, Blanco Prieto S, Ibanez B, Filgueiras Rama D, Iniguez Romato A, et al. Impact of malnutrition, on the relationship between obesity and mortality in patients with partial fibrillation. Eur Heart J. 2021;42(suppl 1)3ehab724.0443. doi: 10.1093/eurheart/ehab724.0443 27. Kim D, Shim J, Kim YG, Yu HT, Kim T-H, Uhm J-S, Choi J-I, Joung B, Lee M-H, Kim Y-H, et al. Malnutrition and risk of procedural complications in patients with atrial fibrillation undergoing catheter ablation. Front Cardiovasc Med 2021;8:736042. doi: 10.3389/fcvm.2021;736042 28. Rivera: Sarica-diga, Jacžag-Luengo B, Martinez-Montesinos L, Lopez-Galvez R, Garcia-Tomas L, Lip GYH, Marin F, Roldan V. Multimorbidity, frailty and malnutrition: moving beyond traditional risk factors for risk assessment in afri: fibrillation: the Murcia Atrial Fibrillation Project II. Eur Heart J. 2022;43(supp 2):ehac544.635 29. Hermesh I, Hajos J, Mashiach T, Bozhko M, Shani L, Nir RR, Bolotin G. Malnutrition in cardiac surgery: food for thought. Eur J Prev Cardiol. 2014;21:475-483. doi: 10.1177/2047487312452969 30. Liu Z, Shen Z, Zang W, Zhou J, Yu Z, Zhang P, Yan X. Development and validation of global leadership initiative on malnutrition for prognostic prediction in patients who underwent cardiac surgery. Nutrients. 2022;14:2409. doi: 10.3390/ru.14122409 31. Ringatiene D, Gineityte D, Vicka V, Zvirblis T, Norkiene I, Sipylaite J, Irius A, Ivaskevicius J. Malnutrition assessed by phase angle determines outcomes in low-risk cardiac surgery patients. Clin Nutr. 2016;35:1328-1332. doi: 10.1016/j.clnu.2016.02.010 32. Bayir H, Yildiz I. Malnutrition and adverse effects in cardiac surgery. Thorac Cardiovasc Surg 2015;63:349-350. doi: 10.1055/s-0035-1548999 33. Tonet E, Campana R, Cagioni S, Gibino F, Fiorio A, Chiaranda G, Zagnoni S, Casella G, Campo G. Tools for the assessment of the malnutrition status and possible interventions in elderly with cardiovascular diseases. J Clin Med. 2021;10:1508. doi: 10.3390/jcm10071508 34. Uhl S, Siddique SM, Bloschakich A, McKeever W, D'Anci K, Leas B, Mull NK, Comper, C Lewis JD, Wu GD, et al. Interventions for malnutrition in hospitalized adults: a systematic review and meta-analysis. J Hosp Med. 2022;17:556-564. doi: 10.1002/jhm.12891 35. Kootaka Y, Kamiya K, Damazaki N, Nozaki K, Ichikawa T, Nakamura T, Yamashita M, Maekawa E, Reed JL, Yamaoka-Tojo M, et al. The GLIM criteria for defining malnutrition can predict physical function and prognosis in patients with cardiovascular disease. Clin Nutr. 2021;40:146-152. doi: 10.1016/j.chinu.2020.04.038 36. Deleted of proof 37. Ignacio de Ulibarri J, Gonzalez-Madrono A, de Villar NG, Gonzalez P, Gonzalez B, Mancha A. Rodriguez F, Fernandez G. CONUT: a tool for

Vest et al

Malnutrition and Cachexia in Inpatients With Acute Cardiac Conditions

controlling nutritional status: first validation in a hospital population. Nutr Hosp.2005;20:38-45. 38. Hu Y, Yang H, Zhou Y, Liu X, Zou C, Ji S, Liang T. Prediction of all-cause mortality with malnutrition assessed by nutritional screening and assessment tools in patients with heart failure systems review. Nutr Metab Cardiovasc Dis. 2022;32:1361–1374. doi: 10.1016/j.numecd.2022.03.009. 39. Deleted in proof. 40. He F, Huang H, Xu W, Cui K, Ruan Y, Guo Y, Wang J, Bin J, Wang Y, Chen Z. Y. Prognostic impact of malnutrition in patients with coronary artery disease: a systematic review and meta-analysis. Nutr Rev. 2024;82:1013–1027. doi: 10.1093/nutrit/nuad108 41. Rodighiero J. Leville Ne, Shen S, Ekmekjian T, Ades M, Drudi L. MA. scoping review of malnutrition in patients undergoing interventions for peripheral arterial disease. J Vasc Surg. 2022;76:1742–1754.e3. doi: 10.1016/j.ivjs.2022.04.044 42. Bouillanne O, Morineu G, Dupont C, Coulombel I, Vincent JP, Nicolis I, Benazeth S, Cynober L, Aussel C. Geriatric Nutritional Risk Index: a new index for evaluating atr-risk elderly medical patients. Am J Clin Nutr. 2005;82:777–783. doi: 10.1039/ajcn/82.774/87. 43. Power L, Mullally D, Gibney ER, Clarke M, Visser M, Volkert D, Bardon L, de van der Schueren MAE, Corish CA MaNuEL Consortium. A review of the validity of malnutrition screening tools used in older adults in community and healthcare settings: maNauEL study. Clin Nutr ESPEN 2018;24:1–13. doi: 10.1016/j.jcnesp.2018.02.005 44. Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony R, Charlton KE, Maggio M, et al; MNA-international Group. Validation of the Mini Nutritional Assessment Short-Form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging, 2009;13:782–788. doi: 10.1007/s12603-009-0214-7 45. Jayawardena R, Lokunarangoda NC, Ranathunga I, Sanharaja WS, Walawwatta AO, Pathirana AK. Predicting clinical outcome of cardiac patients by six malnutrition screening tools. BMC Nutr. 2016;2. doi: 10.1186/s40795-016-0044-z 46. Cortes-Aguilar R, Malih N, Fredmes S, Yanez A, Bennasar-Veny M. Validity of nutrition screening tools for risk of malnutrition among hospitalized adult patients: a systematic review and meta-analysis. Clin Nutr. 2024;43:1094–1116. doi: 10.1016/j.cinmsc.2023;0.03.008 47. Skipper A, Coltman A, Tomesko J, Charney P, Poracari J, Piemonte TA, Handu D, Cheng FW. Position of the Academy of Nutrition and Dietetics: malnutrition (undernutrition) screening tools for all adults. J Acad Nutet D 2020;120:709–713, doi: 10.1016/j.ind:2019.09.011 48. Ferguson M. Capraš J. Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition, 1999;15:458–464. doi: 10.1016/s0899-9007(99)00084-2 49. Heyland DK, Dhalval R, Day Agi J. Identity–Vich, 2022; il patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care. 2011;15:R268. doi: 10.1186/cc10546 50. Zheng C, Xie K, Li XK, Wang GM, Luo J, Zhang C, Jiang ZS, Wang YL, Luo C, Qiang Y, et al. The prognostic modified of��utRIC score for patients in cardiothoracic surgery recovery unit: a retrospective cohort study. J Hum Nutr Diet. 2021;34:926–934. doi: 10.1111/jhn.12899 51. Malnutrition Advisory Group. A consistent and reliable tool for malnutrition screening. Nurss 2003;99:26–27. 52. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z, Ad Hoc EWG. Nutritional Risk Screening (NRS 2002) a new method based on an analysis of controlled clinical trials. Clin Nutr. 2003;22:321–336. doi: 10.1016/s0261-5614(02)00214-5 53. Buzby GP Mullen JL, Matthews DC, Hobbs CL Rosato EF Prognost nutritional index in gastrointestinal surgery. Am J Surg. 1980;139:160–167. doi: 10.1016/002-9610(02)046-9 54. Baker JP, Detsky AS, Wesson DE, Wolman SL, Stewart S, Whitewell J, Langer B, Jeejeehboy KN. Nutritional assessment: a comparison of clinical judgement and objective measurements. N Engl J Med 1982:306:969-972. doi: 10.1056/NEJMJ19824223061606 55. Kruizenga HM, Seidell JC, de Vet HC, Wierdsma NJ, van Bokhorst-de van der Schueren MA. Development and validation of a hospital screening tool for malnutrition: the short Nutritional Assessment Questionnaire (SNAQ). Clin Nutr. 2005;24:75–82. doi: 10.1016/j.cindu.2004.07.015 56. Do S, Iwata H, Wada H, Funamizu T, Shitara J, Endo H, Naito R, Konishi H, Tsuboi S, Ogita M et al. A novel and simply calculated nutritional index serves as a useful prognostic indicator in patients with coronary artery disease. Int J Cardiol. 2018;262:92–98. doi: 10.1016/j.jicin.2018.02.039

57. Argiles JM, Betancourt A, Guardia-Olmos J, Pero-Cebollero M, Lopez-Soriano FIJ, Madeddu C, Serpe R, Busquets S. Validation of the CA-chexia SCOre (CASCO): staging cancer patients: the use of miniCASCO as a simplified tool. Front Physiol: 2017;8:92. doi: 10.3389/fphys.201700092 5821 PAP, Micciolo R, Rubele S, Fantin F, Caliari C, Zoico E, Mazzali G, Ferrari E, Volpato S, Zamboni M. Assessing the risk of sarcopenia in the elderly: the Mini Sarcopenia Risk Assessment (MSRA) questionnaire. J Nutr Health Aging. 2017;21:743-749. doi: 10.1007/s/12603-017-0921-4 59. Malmstrom TK, Morley JE. SARC-F: a simple questionnaire to rap-idy diagnose sarcopenia. J Am Med Dir Assoc. 2013;14:531-532. doi: 10.1016/j.jamda.2013.05.018 60. Noda T, Kamiya K, Hamazaki N, Nozaki K, Ichikawa T, Yamashita M, Uchida S, U, Neso K, Maakawa E, Terada T, et al. SARC-F predicts poor motor func-tion, quality of life, and prognosis in older patients with cardiovascular disease and cognitive impairment. Exp Gerontol. 2023;171:112021. doi: 10.1016/j.exger.2022.112-2021 61. Noda T, Kamiya K, Hamazaki N, Yamashita M, Miki T, Nozaki K, Uchida S, Ueno K, Maakawa E, Terada T, et al. Screening for sarcopenia with SARC-F in older patients hospitalized with cardiovascular disease. Eur J Cardiovasc Nurs. 2024;23:675-684. doi: 10.1093/eurcn/jzvae017 62. Chen LK, Woo J, Assartachai P, Auyeung TW, Chou MY, Ijlima K, Jang HC, Kang L, Kim M, Kim S, et al. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J Am Med Dir Assoc. 2020;21:300-307.2e. doi: 10.1016/j.jamda.2019.12.012 63. Kashani KB, Frazee EN, Kukralova L, Sarvottam K, Herasevich V, Young PM, Kashyap R, Lieske J.C. Evaluating muscle mass by using markers of kidney function: development of the sarcopenia index. Crit Care Med. 2017;45:e23-e29. doi: 10.1097/CCM.00000000000002013 64. Ballew SH, Zhou L, Surapaneni A, Grams ME, Windham BG, Selvin E, Coresh J, Miao S, Inker LA, Levey AS. A novel creatinine muscle index based on creatinine filtration: associations with frailty and mortality. J Am Soc Nephrol. 2023;34:49-56-504. doi: 10.1681/ASN.00000000000000037 65. Won MH, Yun KH, Kim H, Son YJ. Prognostic role of sarcopenia on major adverse cardiac events among patients who underwent successful percutaneous coronary intervention: a retrospective cohort study. Eur J Cardiovasc Nurs. 2024;23:287-295. doi: 10.1093/eurj/zwad080 66. Lee HS, Park KW, Kang J, Ki YJ, Chang M, Han JK, Yang HM, Kang HJ, Koo BK, Kim HS. Sarcopenia index as a predictor of clinical outcomes in older patients with coronary artery disease. J Clin Med. 2020;9:3121. doi: 10.1039/jc/9103121 67. Cai X, Hu J, Wang M, Wen W, Wang J, Yang W, Dang Y, Luo Q, Hong J, Li N. Association between the sarcopenia index and the risk of stroke in elderly patients with hypertension: a cohort study. Aging (Albany NY). 2023;15:2005-2032. doi: 10.18632/aging.204587 68. He Liq J, Gu J, Xee L, Zhang L, Yang M, A sarcopenia index based on serum creatinine and cystic and accurately detect either low muscle mass or sarcopenia in urban community-dwelling older people. Sci Rep. 2018:88:11534. doi: 10.1038/s41598-018-29808-6 69. Jensen GL, Mirtallo J, Compher C, Dhaliwal R, Forbes A, Grijalba RF, Hardy G, Kondrup J, Labadarios D, Nyulasi I, et al; International Consensus Guideline Committee. AndI starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr. 2010;34:156-159. doi: 10.1177/0148607110361910 70. Jimenez EY, Lamers-Johnson E, Long JM, McCabe G, Ma X, Woodcock L, Bliss C, Abram JK, Steiber AL. Predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators to diagnose malnutrition tool in hospitalized adults: a cohort study. Am J Clin Nutr. 2024;119:779-787. doi: 10.1016/j.ajcnut.2023.12.012 71. Cederholm T, Jensen GL, Correia M, Gonzalez MC, Fukushima R, Higashiguchi T, Baptista G, Barazzoni R, Blauw R, Coats AJS, et al; GLIM Core Leadership Committee, GLIM Working Group. GLIM criteria for the diagnosis of malnutrition: a consensus report from the global clinical nutrition community. J Cacheria Sarcopenia Muscle. 2019;10:207-217. doi: 10.1002/jc/sm.12383 72. Poulter S, Steber B, Baguley B, Edbrooke L, Kiss N. Comparison of the GLIM, ESPEN and ICD-10 criteria to diagnose malnutrition and predict 30-day outcomes: an observational study in an oncology population. Nutrients. 2021;13:2602. doi: 10.3390/nu13082602 73. Clark AB, Reijnierse EM, Lim WK, Maier AB. Prevalence of malnutrition comparing the GLIM criteria, ESPEN definition and MST malnutrition risk in geriatric rehabilitation patients: RESORT. Clin Nutr. 2020;39:3504-3511. doi: 10.1016/j.jclu.2020.03.015

CLIMAL STATEMENTS AND GUDENIES

GLOBAL STATEMENTS

Vest et al

Malnutrition and Cachexia in Inpatients With Acute Cardiac Conditions

74. Allard JP, Keller H, Gramlich L, Jeeeböhny KN, Laporte M, Duerksen DR. GLIM criteria has fair sensitivity and specificity for diagnosing malnutrition when using SGA as comparator. Clin Nutr. 2019;39:2771–2777i. doi:10.1016/j.cinu2019.12:00475. 75. Evans DC, Corkins MR, Malone A, Miller S, Magnesen KM, Guenter P, Jensen GL; ASPEN Malnutrition Committee. The use of visceral proteins as nutrition markers: an ASPEN position paper. Nutr Clin Pact 2021;36:22–28. doi:10.1002/ncp.10588 76. Pray R, Riskin S. The history and faults of the body mass index and where to look next: a literature review. Cureus 2023;15:4e2830. doi:10.7759/cureus.48230 77. Sweatt K, Garvey W, Martins C. Strengths and limitations of BMI in the diagnosis of obesity: what is the path forward? Curr Obes Rep. 2024;13:584–595. doi: 10.1007/s13679-024-00580-1 78. Tham KW, Abdul Ghani R, Cua SC, Deerochanawong C, Fojas M, Hocking, S, Lee J, Nam TO, Pathan F, Saboo B, et al. Obesity in South and South-east Asia: a new consensus on care and management. Obes Rev. 2023;24:1e3520. doi: 10.1111/07br/135202;24:1e3520. doi: 10.1111/07br/135202;24:1e3520. doi: 10.1111/07br/135202;24:1e3520. doi: 10.1111/07<br>79. WHO Expert Consultation. Appropriate body-mass index as for Asian populations and its implications for policy and intervention strategies. Lancet 2004;36:1537–163. doi: 10.1016/S10-47:6736(03)151268–3<3<start>8<content>93. Dickerson RN. Nitrogen balance and protein requirements for critically ill older patients. Nutrients. 2016;8:226. doi: 10.3390/nu8040226 <start>9<content>94. Esteban-Fernandez A, Viellar-Taibo R, Alejo M, Arroyo D, Bonilla Palomas JL, Cachero M, Joaquin C, Mendez Bailon M, Perez-Rivera JA, Romero-Vigara JC, et al. Diagnosis and management of malnutrition in patients with heart failure. J Clin Med. 2023;12:321-262. doi: 10.1016/S2213-8587(24)00316-4 <start>0<content>80. Rubino F, Cummings DE, Eckel RH, Cohen RV, Wilding JPH, Brown WA, Stanford F, Batterham RL, Faroojo IS, Farpou-Lambert NJ, et al. Defin- tion and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. 2025;13:221-262. doi: 10.1016/S2213-8587(24)00316-4<start>1<content>76. Pray R, Riskin S. The history and faults of the body mass index and where to look next: a literature review. Cureus 2023;15:4e2830. doi: 10.1111/07<br>79.0.11759/cureus.48230<start>2<content>80. Delfian R, Patour-Lambert NJ, Atal, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Funt, Res- Pena J, J, Alcal. Diany, S, Fu

93. Dickerson RN. Nitrogen balance and protein requirements for critically ill older patients. Nutrients. 2016;8:226. doi: 10.3390/nu8040226 94. Esteban-Fernandez A, Villar-Taibo R, Alejo M, Arroyo D, Bonilla Palomas JL, Cachero M, Joaquin C, Mendez Bailon M, Perez-Rivera JA, Romero-Vigara JC, et al. Diagnosis and management of malnutrition in patients with heart failure. J Clin Med. 2023;12:3320. doi: 10.3390/jcm12093320 95. Lichtenstein AH, Appel L.J., Vadiveloo M, Hu FB, Kris-Etherton PM, Rebholz CM, Sacks FM, Thondike AN, Van Horn L, Wylie-Rosett J. 2021 Dietary guidance to improve cardiovascular health: a scientific statement from the American Heart Association. Circulation. 2021;144:e472-e487. doi: 10.1161/CIR.00000000000001031 96. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145:e895-1032. doi: 10.1161/CIR.00000000000001063 97. Ezekowitz JA, Colin-Ramirez E, Ross H, Escobedo J, Macdonald P, Troughton L, Saldariaga C, Alemayehu W, McAlister FA, Arcand J, et al; SODIUM-HF Investigators. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial. Lancet 2022;399:1391~1400. doi: 10.1016/S0140-6736(2022)00369-5 98. Delgado-Lista J, Alcala-Diaz JF, Torres-Pena JD, Quintana-Navarro GM, Fuentes F, Garcia-Rios A, Ortiz-Morales AM, Gonzalez-Requero Al, Perez-Caballero Al, Yubero-Serrano EM, et al; CORDIOPREV: Investigators. Long-term secondary prevention of cardiovascular disease with a Mediterranean diet and a low-fat diet (CORDIOPREV): a randomised controlled trial. Lancet. 2022;399:1876-1885. doi: 10.1016/S0140-6736(2022)00122-2 97. Estruch T, Ros E, Selas-Salvado J, Covas MI, Corella D, Aros F, Gomez-Gracia, R-Euiz Gutierrez V, Fiol M, Lapetra J, et al; PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet with extra-virgin olive oil or nuts. N Engl J Med 2018;378:e34. doi: 10.1056/NEJ.Moa1800389 100. Herrmann JJ, Brunner-La Rocca HP, Baltussen L, Beckers-Wesche F, Bekkers S, Bellersen L, van Eck JWM, Hassing HC, Jaarsma T, Linssen GCM, et al. Liberal fluid intake versus fluid restriction in chronic heart failure: a randomized clinical trial. Nat Med. 2025;31:2062–2068. doi: 10.1038/s4151-0052-03628-4 101. Zeanandin G, Molato O, Le Duff F, Guerin O, Hebuterne X, Schneider SM. Impact of relativity-diefing on the risk of undernutrition in a free-living elderly population. Clin Nutr. 2012;31:69–73. doi: 10.1016/j.clnu.2011.08.007 102. Jefferson K, Ahmed M, Choleva M, Mak S, Allard JP, Newton GE, Arcand J. Effect of a sodium-restricted diet on intake of other nutrients in heart failure: implications for research and clinical practice. J Card Fail. 2015;21:959–962. doi: 10.1016/j.cardail.2015.10.002 103. Wong A, Huang Y, Sowa PM, Banks MD, Bauer JD. Effectiveness of dietary counseling with without nutrition supplementation in hospitalized patients who are malnourished or at risk of malnutrition: a systematic review and meta-analysis. JPEN J Parenter Enteral Nutr. 2022;46:1502–1521. doi: 10.1002/j�pn.2395 104. Schuetz P, Fehr R, Baechli V, Geiser M, Deiss M, Gomes F, Kutz A, Tribolet P, Bregrenzer T, Braun N, et al. Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial. Lancet. 2019;393:2312–2291. doi: 10.1016/s0140-6736(18)32776-4 105. Hersberger L L, Agterg H, Bargetzi A, Bargetzi L, Kagi-Braun N, Tribolet P, Gomes F, Hoess C, Pavlicek V, et al. Individualized nutritional support for hospitalized patients with chronic heart failure. J Am Coll Cardiol. 2021;77:2307–2319. doi: 10.1016/j/jacc.2021.03.232 106. Lennie TA, Andrese C, Rayens MK, Song EK, Dunbar SB, Pressler SJ, Heo S, Kim J, Moser DK. Micronutrient deficiency independently predicts time to event in patients with heart failure. J Am Heart Assoc. 2018;7:e007251. doi: 10.1016/J.AHA.117007251 107. Song EK, Kang S-M. Micronutrient deficiency independently predicts adverse health outcomes in patients with heart failure. J Cardiovasc Nurs. 2017;32:47-53. doi: 10.1097/JCN.00000000000000304 108. Keith ME, Walsh, Paglinan S, Thirugnanam S, Darling PB, Hanninen SA, Thirugnanam S, Leong-Poi H, Barr A, Sole MJ. B-vitamin deficiency in hospitalized patients with heart failure. J Am Diet Assoc. 2009;109:1406–1410. doi: 10.1016/j/jalda.2009.05.011 109. Jain A Mehta R, Al-Ari, Martin she DE. Determining the role of thiamine deficiency in systolic heart failure: a meta-analysis and systematic review. J Card Fail. 2015;21:1000–1007. doi: 10.1016/j.cardail.2015.10.005

Vest et al.

Malnutrition and Cachexia in Inpatients With Acute Cardiac Conditions

CLIMPAL STATEMENTS AND BUDATEMENTS

110. Sharma A, Fonarow GC, Butler J, Ezekowitz JA, Felker GM. Coenzyme O10 and heart failure: a state-of-the-art review. Circ Heart Fail. 2016;9:e002639. doi: 10.1161/CIRCHEARTFAILURE.115.002639 111. West AR, Chan M, Deswal A, Giverz MM, Lekavich C, Lennie T, Litwin SE, Parsly L, Rodgers JE, Rich MW, et al. Nutrition, obesity, and cachexia in patients with heart failure: a consensus statement from the Heart Failure Society of America Scientific Statements Committee. J Card Fail 2019;25:380-400. doi: 10.1016/j.cardail.2019.03.007 112. Mortensen SA, Rosenfeldt F, Kumar A, Dolliner P, Filipiak KJ, Pella D, Alehagen U, Sturer G, Littanu GP, O-SYMBIO Study Investigators. The effect of coenzyme Q10 on morbidity and mortality in chronic heart failure: results from Q-SYMBIO A: randomized double-blind trial. JACC Heart failure. 2014;2:641-649. doi: 10.1016/j.chfjst.2014.06.008 113. Schlein KM, Coulter SP. Best practices for determining resting energy expenditure in critically ill adults. Nuñ Clin Pract 2014;29:44-45-55, doi: 10.1177/0884533613515002 114. Deleted in proof 115. Deleted in proof 116. Deleted in proof 117. Deleted in proof 118. Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, Phillips S, Sieber C, Stehle P, Teta D, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PRO-TAGE Study Group. J Am Med Dir Assoc. 2013;14:542-559. doi: 10.1016/j.jamda.2013.05.021 119. Billingsley HHE, Hummel SL, Carbone S. The role of diet and nutrition in heart failure: a state-of-the-art narrative review. Pro Cardiovasc Dis. 2020;63:538-551. doi: 10.1016/j.pcad.2020.08.004 119. Katano S, Yaro T, Kouzu H, Ohori K, Shimorna K, Honma S, Nagoka R, Inoue T, Takamura Y, Ishigo T, et al. Energy intake during hospital stay predicts all-cause mortality after discharge independently of nutritional status in elderly heart failure patients. Clin Res Cardiol. 2021;110:1202-1220. doi: 10.1007/s00392-020-01774-y 112. Aquilani R, Opasich C, Verri M, Boschi F, Febo O, Pasini E, Pastoris O. Is nu-tritional intake adequate in chronic heart failure patients? J Am Coll Cardiol. 2003;42:1218-1223. doi: 10.1016/s0735-1097(03)00946-x 129. Kuehneman T, Gregory M, Waal D, Davidson P, Frickel R, King C, Gradwell E, Handu D. Academy of Nutrition and Dietetics evidence-based practice guideline for the management of heart failure in adults. J Acad Nut Dietetics. 2018;118:2331-2345, doi: 10.1016/j.and/2018.03.004 123. Virtan HEK, Voutilainen S, Koskinen TT, MursuJ, Tuomainen T-P, Virtanen JK. Intake of différenti dietary proteins and jijk of heart failure in jinnen. Credit Heart. 2011;1:1-12: doi: 10.1016/circheart failure.117.004531 124. Wang Z, Bergeron N, Levison BS, Li XS, Chiu S, Jia X, Köeth RA, Li L, Wu Y, Tang WHV, et al. impact of chronic dietary ed. will, while me's or non-meat protein on trimethylamine N-oxide metabolism and renal ex-cretion in healthy men and women. Eur Heart J. 2019;40:583-594. doi: 10.1033/eurheartyl/ehy/399 125. Levey AS, Greene T, Sarnak MJ, Wang X, Beck GJ, Kusek JW, Collins AJ, Kopple JD. Effect of dietary protein restriction on the progression of kidney disease: long-term follow-up of the Modification of Diet in Renal Disease (MDRD) study. Am J Kidney Dis. 2006;48:879-888. doi: 10.1053/jaikd.2006.08.023 126. Levey AS, Adler S, Caggiula AW, England BK, Greene T, Hunsicker LG, Kusek JW, Rogers NL, Teschan PE. Effects of dietary protein restriction on the progression of advanced renal disease in the Modification of Diet in Renal Disease study. Am J Kidney Dis. 1996;27:652-663. doi: 10.1016/s0272-6386(96)90099-2 127. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidley Int 2024;10:5511-S731-S74.10.1016/j.kint-2023.10.018 128. Carballo-Casla A, Avesani CM, Beridze G, Ortolá R, García-Esquinas E, Lopez-Garia E, Dai L, Dunkm. Main, Stvinkelip N, Lindholm B, et al. Protein intake and mortality in older adults with chronic kidney disease. JAMA Netw Open. 2024;7:e2426577. doi: 10.1001/jamanetworkopen.2024.26577 129. Kha Z Y. Qian O. Protein nutrition and malnutrition protection tools in patients with acute Nutrients. 2017;9:208. doi: 10.3390/nu/9030208 130. Sze S, Zhang J, Pellicori P, Morgan D, Hoye A, Clark AL. Prognostic value of simple frailty and malnutrition screening tools in patients with acute heart failure due to left ventricular systolic dysfunction. Clin Res Cardiol. 2017;106:533-541. doi: 10.1007/s00392-017-1082-5 131. Valentova M, von Haehling S, Baudit J, Doehner W, Ebner N, Bekfani T, Elsner S, Slizuki V, Scherbakov N, Murin J, et al. Intestinal congestion and

right ventricular dysfunction: a link with appetite loss, inflammation, and cachexia in chronic heart failure. Eur Heart J. 2016;37:1684-1691. doi: 10.1093/eurheartj/ehw/2008 132. Bonilla-Palomas JL, Gámez-López AL, Castillo-Domínguez JC, Moreno-Conde M. López Ibáñez MC, Alhambra Expósito R, Ramiro Ortega E, Anguita-Sánchez MP, Villar-Ráez A. Nutritional intervention in malnourished hospitalized patients with heart failure. Arch Med Res. 2016;47:535-540. doi: 10.1016/jarcmed.2016.11.005 133. da Silva JSV, Seres DS, Sabino K, Adams SC, Berdahl GJ, Citty SW, Cober MP Evans DC, Greaves JR, Gura KM, et al; Parenteral Nutrition Safety and Clinical Practice Committees, American Society for Parenteral and Enteral Nutrition. ASPEN consensus recommendations for refeeding syndrome. Nutr Clin Pract. 2020;35:178-195. doi: 10.1002/ncp.10474 134. Taylor BE, McClave SA, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, et al; Society of Critical Care Medicine. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (AS.PEN). Crit Care Med. 2016;44:390-438. doi: 10.1097/CCM.000000000000001525 135. Singer P, Blaser AR, Berger MM, Calder PC, Casa R, M, Hiesmayr M, Mayer K, Montejo-Gonzalez JC, Pichard C, Preiser JC, et al. ESPEN practical and partially revised guideline: clinical nutrition in the intensive care unit. Clin Nutr. 2023;42:1671-1689. doi: 10.1016/j.clnu.2023.07.011 136. Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med. 2009;35:2018-2027. doi: 10.1007/s/00134-009-1664-4 137. Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29:2264-2270. doi: 10.1097/00003246-200112000-00005 138. Zaloga GP, Roberts PR, Marik P. Feeding the hemodynamically unstable patient: a critical evaluation of the evidence. Nutr Clin Pract. 2003;18:285-293. doi: 10.1177/0115426503018004285 139. Reignier J, Plantefeve G, Mira JP, Argaud Asfar P, Aissaoui N, Badie J. Botce, NV. Brisard L, Bui HN, et al; NUTRIREA-3 Trial Investigators. Low versus standard calorie and protein feeding in ventilated adults with shock: a randomized, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3). Lancet Respir Med. 2023;11:602-612. doi: 10.1016/S2213-2600(23)00092-9 140. Comissão PH. Stefani al. Viana LV. Mortality and overall and specific infection complication rates in patients who receive parenteral nutrition: systematic review and meta-analysis with trial sequential analysis. Am J Clin Nutr. 2021;1141-1843-1845, doi: 10.1093/ajcn/nqab218 141. Leone M, Bechis C, Baunstarck K, Ouattara A, Collange O, Augustin P, Annane D, Arbelot C, Asehnoune K, Baldesi O, et al. Outcome of acute mesenteric ischemia in the intensive care unit: a retrospective, multi-center study of 780 cases. Intensive Care Med. 2015;41:667-676. doi: 10.1007/s00134-015-3690-8 142. Fordyce CB, Katz JN, Alviar CL Arslanian-Engoren C, Bohula EA, Geller BJ, Hollenberg SM, Jentzer JC, Sims DB, Washam JB, et al; on behalf of the American Heart Association Council on Clinical Cardiology; Council on Arterioscleris, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; and Stroke Council. Prevention of complications in the cardiac intensive care unit: a scientific statement from the American Heart Association. Circulation. 2020;142:e379-e406. doi: 10.1161/CIR.00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000

CLIMUAL STATEMENTS AND AMEDIES

Vest et al

Malnutrition and Cachexia in Inpatients With Acute Cardiac Conditions

pragmatic, registry-based randomised trial. Lancet. 2023;401:568–576. doi: 10.1016/S0140-6736(20)22469-2

146. Bels JLM, Thiessen S, van Gassel RJJ, Beishuizen A, De Bie Dekker A, Fraipont V Lamote S, Ledoux D, Scheeren C, De Waele E, et al; PRECISe Study Team. Effect of high versus standard protein provision on functional recovery in people with critical illness (PRECISe): an investigator initiated, double-blinded, multicentre, parallel-group, randomised controlled trial in Belgium and the Netherlands. Lancet. 2024;404:659–669. doi: 10.1016/S0140-6736(24)01304-7

147. Nakamura K, Nakano H, Naraba H, Mochizuki M, Takahashi Y, Sonoo T, Hashimoto H, Morimura N. High protein versus medium protein delivery under equal total energy delivery in critical care: a randomized controlled trial. Clin Nutr. 2021;40:796-803. doi: 10.1016/j.clnu.2020.07:036

148. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, et al. Society of Critical Care Medicine. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Entual Nutrition (A.S.PEN.). JPEN J.EP Narenter Enteral Nutr. 2016;40:159-211. doi: 10.1177/0148607115621863

149. Compher C, Bingham AL, McCall M, Patell J. Rice TW, Braunschweig C, McKeever L. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: the American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2022;46:12-41. doi: 10.1002/j.pen-2267

150. Gramlich, Guenter P. Enteral nutrition in hospitalized adults. N Engl J Med 2025;392:1518-1530. doi: 10.1056/NEJMra2406954

151. De Backer D, Creteur J, Dubois MJ, Sakr Y, Vincent JL. Microvascular alterations in patients with acute severe heart failure and cardogenic shock. Am Heart J. 2004;147:91–99. doi: 10.1016/j.jahj.2003.07:006

152. Hansen HJ, Engell HC, Ring-Larsen, H Ranek, L. Spanlichine blood flow in patients with abdominal angina before and after arterial reconstruction: a proposal for a diagnostic test. Ann Surg. 1977; 1863–216:220. doi: 10.1097/00000658-197708000-00016

153. McClave SA, Chang WK. Feeding the hypotensive patient: does enteral feeding precipitate or protect against ischemic bowel? Nut Clin Pract. 2003;18:279–284. doi: 10.1177/0115426503018004279

154. Regnier J, Boisrame-Helms J, Brisard L, Lascarrou JB, Ait Hssain A, Anguel N, Argaud L, Asehnoune K, Asfar P, Bellec F, et al; NUTRIREA-2 Trial Investigators. Enderal versus parenteral early nutrition in ventilated adults with shock; a randomised, controlled, multicentre, open-label, parallel group study (NUTRIREA-2) Lanelet 2079;391:183:148.30.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1016/S0140-6736(17)32146-33.10.1

155. Landais M, Nay MA, Auchabie J, Hubert N, Frerou A, Yehia A, Mercat A, Jonas M, Martino F, M. et al. REVA Network and CRIGS-TriggerSEP F-CCRIN Research Network. Continued enteral nutrition until extubation compared with fasting before extubation in patients in the intensive care unit. An open-bel, cluster-randomised, parallel-group, non-inferiority trial. Lancet Respir Med. 2023;11:31:39:328. doi: 10.1016/S2213-2600(22)00431-13

156. Harvey Se, Parrott F, Harrison DA, Bear DE, Segaran E, Beale R, Bellangan G, Leonard R, Mythen MG, Rowan KM; CALORIES Trial Investigators. Trial of the route of early nutritional support in critically ill adults. N Engl J Med 2014;371:1673-1684. doi: 10.1056/NEJMoa4098608

157. Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga in H. Differences in effect of early entoral nutrition on mortality among ventilated adults with shock requiring low, medium-, and high-dose norrenaline: a propensity-matched analysis. Clin Nutr. 2020;39:460–467. doi: 10.1016/j.clinu.2019.02:020

158. Manel EE, Muvezich KM. Telerability and safety of enteral nutrition in critically ill patients receiving intravenous vasopressor therapy. JPEN J. Penter 前enter Nutral Nutr. 2013:67:641-651. doi: 10.1171/07460172147042640

159. Nuzzo A, Maggiori L, Ronot M, Becac A, Plessier A, Gault N, Joly F, Castier Y, Vilgrain V, Paugam C, et al. Predictive factors of intestinal necrosis in acute mesenteric ischemia: prospective study from an intestinal stroke center. Am J Gastroenterol. 2017;11:2297-605. doi: 10.1038/aig.2017.388

160. Flordelis Lasierra JL, Montejo Gonzalez JC, Lopez Delgado JC, Zarate Chug P, Martinez Loaro-Aranaga F, Lorencio Cardenas C, Bordeje Laguna ML, Maîlech S, Terceros Almanza LJ, Trasmonte Martinez MV, et al; the NUTRIVAD Study Group. Enteral nutrition in critically ill patients under usoactive drug therapy: the NUTRIVAD study. JEPJ N.EP Jenteral Nutr. 2022;46:1420–1430. doi: 10.1002/jenp.2371

161. Gultinez, A. Carlson C. Kalra R. Elliott AM, Yannopoulos D, Bartos. JA Outcomes associated with delayed external feeding after cardiac arrest treated with veno-arterial extracorporeal membrane oxygenation and

targeted temperature management. Resuscitation. 2021;164:20-26. doi: 10.1016/j.resuscitation.2021.04.029

162. Renaudier M, de Roux O, Bougouin W, Boccara J, Dubost B, Attias A, Fiore A, de'Angels N, Folleguet T, Mule S, et al. Acute mesenteric isch-aemia in refractory shock on veno-arteral extracorporeal membrane oxygenation. Eur Heart J Acute Cardiovasc Care. 2020;10:62–70. doi: 10.1177/20488762020915655

163. Ohbe H, Jo T, Yamana H, Matsui H, Fushimi K, Yasunaga H. Early enteral nutrition for cardiogenic or obstructive shock requiring venoarterial extracorporo- real membrane oxygenation: a nationwide inpatient database study. Intensive Care Med. 2018;44:1258-1265. doi: 10.1007/s00134-018-5319-1

164. D'Alesio M, Martucci G, Arcadipane A, Lorusso R, Amrein K. Nutrition during extracorpore life support: a review of pathophysiological bases and application of guidelines. Artif Organs. 2022;46:1240-1248. doi: 10.1111/aer, 04215

165. Park J, Heo E, Song I, Cho J, Namgung H, Lee E, Lee E, Kim DJ. Nutritional support and clinical outcomes in critically ill patients supported with veno-arterial extracorporeal membrane oxygenation. Clin Nutr. 2020;39:2617-2623. doc i: 10.1016/j.clnu.2019.11.036

166. De Waele E, van Zwam K, Mattens S, Staessens K, Diltoer M, Honore PM, Czapla J, Nijs J, La Meir M, Huyghens L, et al. Measuring resting energy expenditure during extracorporeal membrane oxygenation: preliminary clinical experience with a proposed theoretical model. Acta Anaesthesiol Scand. 2015;59:1296-1302. doi: 10.1111/aas.12564

167. De Waele E, Jonckheer J, Pen JJ, Demol J, Staessens K, Puis L, La Meir M, Honore PM, Malbrain MLNG, Spapen HD. Energy expenditure of patients on ECMO: a prospective pilot study. Acta Anaesthesiol Scand. 2019;63:360–364. doi: 10.1111/aas.13287

168. Estensen K, Shekar K, Robins E, McDonald C, Barnett AG, Fraser JF. Macro- and micronutrient disposition in an ex vivo model of extracorporal membrane oxygenation. Intensive Care Med Exp. 2014;2:29. doi: 10.1186/s40635-014-01029-7

169. Mirtallo JM, Ayers P, Boullata J, Gura KM, Plogsted S, Anderson CR, Worthington P. Seres DS, Nicolai E, Alsharman M, et al. ASPEN lipid injectable emulsion safety recommendations: part. 1, background and adult considerations. Nutr Clin Pract. 2020;35:769-7822. doi:10.1002/ncp.10496

170. Bohula EA, Katz JN, van Diepen S, Alviar CL, Baird-Zars VM, Park JG., Barnett CF, Bhattal G, Garsness GW, Burke JA, et al; Critical Care Cardiology Trials Network. Demographics, care patterns, and outcomes of patients [1]distmitted to cardiac intensive care units: the Critical Care Cardiology Trials Network prospective North American multicenter reg-ity ist calciac direct illness. JAMA Cardiol. 2019;4:928-935. doi: 10.1001/j.camagardio.2019.2467

171. Alviar CL, Miller PE, McAreavey D, Katz JN, Lee B, Moriyama B, Sofie a. Vui Despen S, Solomon MA, Morrow DA; ACC Critical Care Cardiology Working Group. Positive pressure ventilation in the cardiac intensive care unit. J Am Coll Cardiol. 2018;72:1532–1553. doi: 101016/j.acc2018.06074

172. Fehler P, Zielinska M, Uchmanowicz B, Juarez-Vela R, Lewandowski L, Zielinski S, Czapla M. Do body mass index and Nutritional Risk Score 2002 influence the in-hospital mortality of patients following cardiac arrest? Nutrients. 2023;15:436. doi: 10.3390/nu15020436

133. Kosmopoulos M. Kalra R. Alexy T, Gaisendres C, Jaeger D, Chahine J, Voicu S, Tsangaris A, Gutierrez AB, Elliott A, et al. The impact of BMI on arrest characteristics and survival of patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation. Resuscitation. 2023;188:109842. doi: 10.1016/j.resuscitation.2023.109842

174. Kim GW, Roh YI, Cha KC, Hwang SO, Han JH, Jung WJ. Diet-related complications according to the timing of enteral nutrition support in patients who recovered from out-of-hospital cardiac arrest: a propensity score matched analysis. Acute Crit Care. 2022;37:610-617. doi: 10.4266/acc.2022.006796

175. JooWJ, IdeK, Kawasaki Y, Takeda C, Seki T, UsuiT, Kawakami K. Effectiveness and safety of early internal nutrition for patients who received targeted temperature management management and a treatment. Resuscitation. 2019;135:191–196. doi: 10.1016/j.resuscitation.2019.01.007

176. Martin M, Reignier J, Le Thuaut A, Lacherade JC, Martin-Lefelve L, Fiancette ET, Maviatier, Lebert C, Bachoumas K, Yehia A, et al. Nutrition during targeted temperature management after cardiac arrest: observational study of neurological outcomes and nutrition tolerance. JPEN J Parenter Enteral Nutr. 2020;44:138–145. doi: 10.1002/jen.1596

177. Williams ML, Nolan JP. Is enteral feeding tolerated during therapeutic hypothermia? Resuscitation. 2014;85:1469-1472. doi: 10.1016/j.resuscitation.2014.08.018

Vest et al.

Malnutrition and Cachexia in Inpatients With Acute Cardiac Conditions

CLIMAL STATEMENTS AND GUEDELINES

178. Tsai YC, Yin CH, Chen JS, Chen YS, Huang SC, Chen JK. Early enteral nutrition in patients with out-of-hospital cardiac arrest under target temperature management was associated with a lower 7-day bacteremia rate: a post-hoc analysis of a retrospective cohort study. J Microbial Immunofect 2024;57:309–319. doi: 10.1016/j.mijm.2023.12.007 179. Gutierrez A, Bartos JA. Reply to: immortal time bias in an observation-al study on enteral nutrition. Res�utification 2021;16:146–147. doi: 10.1016/j.resuscitation.2021.07.032 180. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126:376–393. doi: 10.1097/ALN00000000000001452 181. Bangalore S, Barnsness GW, Dangas GD, Kern MJ, Rao SV, Shore-Lesserson L, Tamis-Holland JE. Evidence-based practices in the cardiac catheterization laboratory: a scientific statement from the American Heart Association. Circulation. 2021;144:e107–e119. doi: 10.1161/CIR.00000000000000996 182. Ferreira D, Hardy J, Meere W, Butal-Simoes, L. Siritharan S, Ray M, French M, McGee M, O'Connor S, Whitehead N, et al. Fasting vs no fasting prior to catheterisation laboratory procedures: the SCOFF trial. Eur Heart J, 2024;45:4900–4998. doi: 10.1093/eurheartj/ehae573 183. Boukantar M, Chiaroni PM, Gallet R, Zamora P, Truong T, Mangiameli A, Rostain L, Tuffreau–Martin AS, Natella PA, Oubaya N, et al. A randomized controlled trial of nonfasting vs fasting before interventional coronary procedures: the TONIC trial. JACC Cardiovasc Interv. 2024;17:1200–1210. doi: 10.1016/j.cijn2024.03.033 184. Bode K, Gerhards M, Doering M, Lucas J, Tijssen J, Dagres N, Hilbert S, Richter S, Nedios S, Lurz J, et al. A randomized trial of non-fasting vs. fasting for cardiac implantable electronic device procedures (Fast-CIED Study). Europea. 2022;24:1617–1626. doi: 10.1093/europae/euac081 185. Liu Z, Zang W, Zhang R, Shen Z. Prognotic implications of Global Leadership Initiative on Malnutrition-defined malnutrition in older patients who underwent cardiac surgery in China. Surgery. 2023;173:472–478. doi: 10.1016/surg.2022.11:008 186. Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khyozhrad A, Gerdisch M, Levy JH, et al. Guidelines for perioperative care in cardiac surgery. Enhanced Recovery After Surgery society recommendations. JAMA Surg. 2019;154:755–766. doi: 10.1001/jamasug.2019.1133 187. Lomorivotov V, Efremov SM, Boboshko VA, Nikolaev DA, Vedernikov PE, Deryagin MN, Lomirovotov VN, Karaskov AM. Prognostic value of nutritional screening tools for patients scheduled for cardiac surge/ichterctic Cardiovasc Thorac Surg. 2013;16:612–618. doi: 10.1093/cvts/ivs549 188. Stoppe C, Goetzenich A, Whitman G, Ohkuma R, Brown T, Hatzakorian Z, Kristal A, Meybohm P, Mechanick J, Evans A, et al. Role of nutrition support in adult diagnostic surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery. Crit Care. 2017;21:131. doi: 11.1086/s13054-017-1690–5. 189. Yu P-J, Cassiere HA, Dellis SL, Manetta F, Kohn N, Hartman AR. Impact of preoperative prealbumin on outcomes after cardiac surgery. JFEN J-Parenter Ental Nutr. 2015;39:870–874. doi: 10.1177/0148607114536735 190. Lauck SB, Wood DA, Achtem L, Baumbusch J, Boone RH, Cheung A, Dvir D, Club D, Tan JS, Ye J, et al. Rask stratification and clinical pathways to optimize length of stay after transcarter aortic valve replacement. Can J Cardiol. 2014;30:1583–1587. doi: 10.1016/j.cjcja.2014.07.012 191. Gillis C, Carl F. Promoting peroperative metabolic and nutritional care. Anesthesiology. 2015;123:1455–1472. doi: 10.1097/ALN.000000000000000795 192. Drover JW, Cahill NE, Kutsogiannis J, Pagliarello G, Wiesmeyer P, Wang M, Day AG, Heyland DK. Nutrition therapy for the critically ill surgical patient: we need to do better JFEN J. Parenter Enteral Nutr. 2010;34:64–652. doi: 10.1177/0148607110372391 193. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst. Rev 2003;CD004423. doi: 10.1002/14651858.CD004423 194. Ljungqvist O. Modulating postoperative insulin resistance by preoperative carbohydrate loading. Best Pract Res Clin Anaesstiel. 2009;23:401–409. doi: 10.1016/j.bpa.2009.08.004 195. Berger MM, Revelly JP, Cayeau MC, Chiolero RL. Enterinal nutrition in critically ill patients with severe hemodynamic failure after cardiopulmonary bypass. Clin Nutr. 2005;24:124–132. doi: 10.1016/j.cjcja.2004.08.005

196. Revelly JP, Tappy L, Berger MM, Gersbach P, Cayeux C, Chiolero R. Early metabolic and splanchnic responses to enteral nutrition in postoperative cardiac surgery patients with circulatory compromise. Intensive Care Med. 2001/27:540-547. doi: 10.1007/s001340100855 197. Melis M, Fichera A, Ferguson MK. Bowel necrosis associated with early jenjal tube feeding: a complication of postoperative enteral nutrition. Arch Sug 2006;1417:701-704. doi: 10.1001/archsurg.141.7701 198. Liu WJ, Zhong J, Luo JC, Zheng JL, Ma JF, Ju MJ, Su Y, Liu K, Tu GW, Luo Z. Early enteral nutrition tolerance in patients with cardiogenic shock requiring mechanical circulatory support. Front Med (Lausanne). 2021;8:765424. doi: 10.3389/fmed.2021.765424 199. Hummel SL, Karmalle W, Gillespie BW, Helmke ST, Teruya S, Wessler JD, Wells JM, Jimenez O, Trumble E, Cornellier M, et al. Geriatric Out-of-Hospital Randomized Meal Trial in Heart Failure (GOURMET-HF) pilot randomized trial: primary results. J Card Fail. 2017;23:830. doi: 10.1016/j�cardif.2017.10.005 200. Doyle J, Alsan M, Skelley N, Lu Y, Cawley J. Effect of an intensive Food-as-Medicine program on health and health care use: a randomized clinical trial. JAMA Intern Med. 2024;184:154-163. doi: 10.1001/jamainternmed.2023.6670 201. Go AS, Tan TC, ToriHEA, KM Laws D, Ambrosy AP, Lee KK, Maring BL, Joy J, Couch C, Hepfer P, et al; KP NOURISH Study Investigators. Effect of medically tailored meals on clinical outcomes in recently hospitalized high-risk adults. Med Care. 2022;60:750-758. doi: 10.1097/MLR.0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000

CLIVAL STATEMENTS AND EDELEINES

Vest et al

Malnutrition and Cachexia in Inpatients With Acute Cardiac Conditions

consensus on definition and diagnosis. Age Ageing. 2019;48:16–31. doi: 10.1093/ageing/afy169

213. Mirzai S, Eck BL, Chen PH, Estep JD, Tang WHW. Current approach to the diagnosis of sarcopenia in heart failure: a narrative review on the role of clinical and imaging assessments. Circ Heart Fail. 2022;15:e009322. doi: 10.1161/CIRCHEARTFAILURE.121.009322

214. Fulster S, Tacke M, Sandek A, Ebner N, Tschope C, Doehner W, Anker SD, von Haehling S. Muscle wasting in patients with chronic heart failure: results from the Studies Investigating Co-Morbidities Aggravating Heart Failure (SICA-HF). Eur Heart J. 2013;34:512–519. doi: 10.1093/eurheart/ehs381

215. Alves FD, Souza GC, Biolo A, Clausell N. Comparison of two bioelectrical impedance devices and dual-energy X-ray absorptiometry to evaluate body composition in heart failure. J Hum Nutr Diet. 2014;27:632–638. doi: 10.1111/jn.12218

216. Casey P, Alasmar M, McLaughlin J, Ang Y, McPhee J, Heire P, Sultan J. The current use of ultrasound to measure skeletal muscle and its ability to predict clinical outcomes: a systematic review. J Cachexia Sarcopenia Muscle. 2022;13:2298-2309. doi: 10.1002/jcsm.13041

217. Cawthon PM, Blackwell T, Cummings SR, Orwell ES, Duchowny KA, Kado DM, Stone KL, Ensrud KE, Cauley JA, Evans WJ. Muscle mass assessed by the D3-creatine dilution method and incident self-reported disability and mortality in a prospective observational study of community-dwelling older men. J Gerontol A Biol Sci Med Sci. 2021;76:123-130. doi: 10.1093/gerona/glaa111

218. Cawthon PM, Orwell E, Peters KE, Ensrud KE, Cauley JA, Kado DM, Stefanick ML, Shikany JM, Strotmeyer ES, Glynn NW, et al; Osteoporotic Fractures in Men (MrOS) Study Research Group. Strong relation between muscle mass determined by D3-creatine dilution, physical performance, and incidence of falls and mobility limitations in a prospective cohort of older men. J Geronitol A Biol Sci Med Sci. 2019;74:844-852. doi: 10.1093/gerona/gly129

219. Groarke JD, Crawford J, Collins SM, Lubaczewski S, Roeland EJ, Naito T, Hendifar AE, Fallon M, Takayama K, Asmis T, et al. Ponsegromab for the treatment of cancer cachexia. N Engl J Med. 2024;391:2291-2303. doi: 10.1056/NEJMoa2409515

220. Driggin E, Goyal P. Malnutrition and sarcopenia as reasons for caution with GLP-1 receptor agonist use in HFpEF. J Card Fail. 2024;30:610–612. doi: 10.1016/j.cardail:2024.201.005

221. Martinez-Gonzalez M, Kim H, Prakash V, Ramos-Lopez O, Zotor F, Martinez JA. Personalized, population and planetary nutrition for precision health. BM Nutr Prev Health. 2021;4:355–358. doi: 10.1136/bmjnph-2021-000235

222. Steen DL, Helsley RN, Bhatt DL, King EC, Summer SS, Fenchel M, Saelens BE, Eckman MH, Couch SC. Efficacy of supermarket and web-based interventions for improving dietary quality: a randomized, controlled trial. Nat Med. 2022;28:2530–2536. doi: 10.1038/s41591-022-02077-7

223. Buys DR, Campbell AD, Godfryd A, Flood K, Kitchin E, Kilgore ML, Allocca S, Locher JL, Meals enhancing nutrition after discharge: findings from a pilot randomized controlled trial. J Acad Nutr Diet. 2017;117:599–608. doi: 10.1016/j.jand.2016.11.005

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